- Email: [email protected]
LITERACY, PARITY, FAMILY PLANNING, AND MATERNAL MORTALITY IN THE THIRD WORLD
865
IMPEDANCE CARDIOGRAPHY IN HEART FAILURE
SIR,-Dr Kong and colleagues (July 19, p 170) have used impedance cardiography as a non-invasive method of measuring cardiac output in vasovagal syncope. We have investigated patients in cardiac failure by impedance cardiography and have observed a characteristic diastolic wave form. Electrical impedance changes within the thorax during the cardiac cycle (see figure) are recorded from four strip electrodes applied to the chest.! Stroke volume can be estimated from the size of the systolic wave form.2 30 patients with clinical evidence of left or right sided heart failure were investigated (mean age 63 years) and the recordings were compared with those from 30 patients with no evidence of cardiac disease (mean age 70 years). Patients were investigated supine and again with their legs elevated to 45 degrees. A diastolic wave, defmed as a deflection above the baseline, was seen in 29 patients with cardiac failure, but in only 3 controls. The abnormal wave form was augmented by leg raising because of enhanced venous return.
being small. The denominators are lower for the multiparous women with no child loss; multiparous women are more likely to have experienced a child loss. Note the denominators in the combined hospital census data: numbers
Child loss Yes No
With
Parity
Shows simultaneous recording of the first derivative of the impedance change (dz/dt) and electrocardiogram (ECG). The 1 S2s-’ standard (A), the maximum dz/dt (B), and the abnormal diastolic wave (0) are marked.
An abnormal diastolic wave has been demonstrated in patients with acute myocardial infarction and was associated with a poor prognosisIn patients with heart failure this may represent the abnormal accumulation of blood within the thorax because of raised ventricular end-diastolic pressures. This simple non-invasive technique may be useful in the diagnosis and management of patients with cardiac failure. National Heart Hospital, London W1
W. N. HUBBARD
National Hospital for Nervous Diseases, London WC1 3BG
D. R. FISH
Worthing General Hospital, Worthing, Sussex
D.
J. MCBRIEN
WN, Fish DR, McBrien DJ. The use of impedance cardiography in heart failure. Int J Cardiol 1986; 12: 71-79 Kubicek WG, Kottke FJ, Ramos MU, et al. The Minnesota impedance cardiograph: Theory and applications. Biomed Engin 1974; 9: 410-16. Ramos MU An abnormal early diastolic impedance waveform. a predictor of poor prognosis m the cardiac patient? Am Heart J 1977; 94: 274-81.
2 3
LITERACY, PARITY, FAMILY PLANNING, AND MATERNAL MORTALITY IN THE THIRD WORLD SIR,-Harrison, Rossiter, and Tan have challenged the statements of Rosenfield and Mainez about an association of high parity and matemal mortality. The data they present are interesting, but they do not refute the Rosenfield and Maine hypothesis, due to insufficient sample size and the analytical approach chosen. Perhaps more importantly, they express unsupported conclusions concerning acceptabiiity of contraception. The mortality data presented show no significant differences, the
Parzty >_
7
703 63
such as maternal mortality, analysis might be case-control improved by design. Confounding variables such as age should not be ignored, even in a brief analysis. Also, in studies of child and infant mortality, increases in mortality have been noted after the second or third birth.4 Therefore, it might have been more interesting to see maternal mortality grouped as parity 1, 2 and 3, and 4 or more. As Harrison et al say, the numbers are too small in the no child loss group to draw conclusions. Harrison et al state that "given the choice, women who will readily opt for family planning are those whose children from previous births are all likely to survive" and that "women who are not assured of the survival of their children will be most reluctant to practise effective contraception". These statements, based on the long-refuted child-replacement theory,3 do not hold up under the test of availability of family-planning services. Northern Nigeria has few sites that offer family planning and it is not clear from their letter whether Harrison et al offer such a service, let alone provide it in a fully accessible manner. In a study in Kenya, a country equally if not better known for its high fertility rate and high desired family size, we found no difference in contraceptive prevalence among non-pregnant women who either had or had not experienced a child loss. When we combined the data from four rural project areas we found: a
No 990 1886
Current contraceptzve 12-2% 11 7%
use
Clearly, there is no significant difference, hence the experience of child loss does not have the impact stated in Harrison and colleagues’ letter. Harrison et al have contributed a great deal to knowledge of maternal mortality. However, conclusions about maternal mortality and acceptance of family planning by different subgroups of the population might be improved if based on data gathered in areas of ready service provision and analysed with epidemiological techniques appropriate to the data. Department of Population Dynamics, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA
MIRIAM H. LABBOK
1. Harrison
KA, Rossiter CE, Tan H. Family planning and maternal mortality m the Third World. Lancet 1986; i: 1441. 2. Rosenfield AL, Maine D. Maternal mortality: a neglected tragedy. Lancet 1985; ii: 83-85. 4. Preston S, ed. The effects of infant and child mortality on fertility. New York: Academic Press, 1977. 3. Maine D. Family planning: its impact on the health of women and children. Center for Population and Family Health, 1981.
**This letter has been shown to Professor Harrison, whose reply to correspondence follows.-ED. L. Dr Labbok, it might help if, with Nigeria as SIR,-In an example, I point out how living conditions favour high parity and why what was said about the acceptance of contraception in relation to child loss is not as farfetched as it may seem. Poverty is widespread. Few can afford a pension and children have to provide for their parents in old age. Thus most couples have many children, hoping that some of those who survive will be sufficiently affluent to support their aged parents and others within the extended family system. In Lagos family planning has not altered family formation it and
1 Hubbard
6
a rare event
Child loss Yes No
Tracings from control patient and from patient in left-ventricular failure (LVF).
<
1614 1709
to
earlier
answer to
patterns: "the desire to have more children is even stronger than the desire to replace previous dead children", with 60% of the couples wanting more than 7 children.In Zaria the scale of child loss was such that among women of very high parity (7-24) the average number of children alive at each delivery was constant, at around 5. It is difficult to see how a lasting reduction in high parity can be achieved through family planning without concomitant development in the economic, educational, and health sectors.
866 Similar conclusions apply to reducing maternal mortality. Labbok’s analysis of data on contraceptive use in Kenya did not take account of the prevalence of contraceptive use in women with varying proportions of child loss from previous births. Furthermore, the pattern of contraceptive use found in the Kenyan villages may reflect not merely the availability of family planning per se but the introduction of other factors, operating at the same time and bringing about a change in behaviour. Dr Walker (July 19, p 162), uses information on trends in literacy and maternal mortality rates in England and Wales to argue that to reduce maternal mortality, establishing effective medical measures is more important than improving socioeconomic status. By 1880 in England and Wales maternal mortality was 5 per 1000 live births, which is comparable with the rate today in much of the third world, and the literacy rate was already over 70 %. Yet, it was not until the mid-1930s that the high maternal mortality rate began its sharp fall. According to Walker, this drop coincided with the establishment of effective obstetric care (blood banks, blood transfusion, antibiotics, and the proper management of hypertensive disease of pregnancy). ’ Walker seems to imply that this trend in England and Wales proves that, if maternal deaths are to be reduced in the third world, we must strengthen medical care delivery systems, including family planning, at the expense of socioeconomic development, especially universal formal education. Walker fails to take into account the fact that the technological developments he cites (and others he did not mention) were themselves consequent on a high literacy rate. Fortunately for the third world, and unlike the position in England and Wales in the 1880s all this knowledge is now available. What is lacking is its wide application. The eradication of mass illiteracy will not only achieve this but also will form the basis for all other developments that are essential if high maternal death rates are to fall. Knowledge through formal education facilitates, for example, the setting up of health care delivery systems and the building and maintenance of essential infrastructure; it encourages self-reliance; it is a very potent instrument for changing people’s attitudes and life-styles; and it fosters political stability and helps to achieve better spread of resources.
There are places in the third world where the medical facilities listed by Walker are available, yet women die needlessly because they cannot make full use of what is there (eg, they cannot afford transportation costs and hospital charges). Walker’s statements do not apply to the poor areas of black Africa about which I can speak from personal experience. Walker feels that because the Zaria data are from a self-selected hospital population, conclusions about maternal mortality by age and parity are suspect. However, the Zaria results are in full accord with population-based studies in showing that pregnancy in older, highly parous women carries greatly increased risks. The relation between the frequencies of twin and triplet pregnancies in booked women followed the pattern expected in population studies.2 ,
Department of Obstetrics and Gynaecology, University of Port Harcourt, PMB 5323, Port Harcourt, Nigeria
K. A. HARRISON
family formation objectives and behaviour, Shomolu, Lagos. Nigerian Med J 1983; 13: 51-56. Harrison KA. Child-bearing, health and social priorities. Br J Obstet Gynaecol 1985; suppl 5: 25-31, 46-60, 100-115.
1. Ekunwe EO. Effect of infant mortality on 2
SALBUTAMOL FOR PERTUSSIS
direct stimulation of central beta-receptors. These potential adverse effects of salbutamol serve to remind us that until a controlled double-blind trial is undertakenthe benefits of salbutamol in pertussis must be evaluated against the potential risks. 4
Poplar Drive, High Beaches, Banstead, Surrey
C. J. BUSHE
CJ. Profound hypophosphataemia in patients collapsing after a "fun run". Br Med J 1986; 292: 898-99. 2. Khanna PB, Davies R. Hallucinations associated with the administration of salbutamol via a nebuliser. Br Med J 1986; 292: 1430. 3. Simon P, Leambier Y, Jouvent K, Pueck A, Allilaire J, Widlocher D. Experimental and clinical evidence of the anti-depressant effect of a beta-adrenergic stimulant. Psychol Med 1978; 8: 335-38. 4. Broomhall J, Herxheimer A. Treatment of whooping cough: the facts. Arch Dis Child 1. Bushe
1984; 59: 185-87.
CHOPSTICKS DYSPHAGIA
SIR,-Sudden and absolute dysphagia is a distressing and serious symptom and may happen in previously healthy people. A 38-year-old man presented as an emergency with absolute dysphagia. 2 days previously, he had noticed sudden onset of severe chest pain whilst eating. The pain subsided but he could not swallow liquids or solids. His wife noticed unusual and severe halitosis. Chest X-rays, including lateral views, were normal. Endoscopy revealed abundant putrifying food debris from the midoesophagus downwards. The debris resembled liver. A small amount of debris was removed and the gastroscope was passed beyond the obstruction, which extended from mid to lower oesophagus (20-30 cm from the incisors). There was no evidence of stricture or external compression of the oesophagus. The patient was then able to swallow normally. Endoscopy on the following day revealed a normal, clear oesophagus with some oedema at 25 cm. Barium swallow was normal. At the time of the acute onset, the patient had been hurriedly eating a Chinese meal with chopsticks, and he recalled having had difficulty in swallowing a leathery piece of liver. He remains well on follow-up. A 34-year-old housewife was eating beef with chopsticks. The beef was tough and a large piece was swallowed with difficulty. Following this she experienced central chest pain and absolute dysphagia. She was seen in hospital two hours later. A chest X-ray was normal. Endoscopy revealed a large piece of beef at 28 cm with saliva above. The bolus was partly removed with forceps and the obstruction was cleared with the gastroscope. Endoscopy and barium swallow were normal. Impaction of food in the normal oesophagus is unusual. Meat is commonly implicated but in most cases the obstruction occurs in an abnormal oesophagus 1,2 as a result of narrowing due to strictures or rings,3which must be excluded by subsequent investigations. No pathological cause was found for the food impaction in these two patients. We suggest that they suffered the consequences of eating inadequately prepared food with chopsticks. With a knife and fork food can be cut up into pieces small enough to swallow easily. Someone inexperienced in the use of chopsticks, which cannot cut, may attempt to swallow a large piece of meat which they would have cut up had they been using a knife and fork. One of the largest studies of foreign bodies within the oesophagus has been reported from Hong Kong.4 We would thus advise caution when eating or preparing food that is to be consumed with the aid of
chopsticks.
SiR,—The debate about the value of salbutamol in infants with pertussis has produced from Dr Brunskill and Dr Langdon the
We thank Prof K. G. M. M. Alberti and Dr S. Proctor for permission to report these two patients.
suggestion that salbutamol has few adverse effects. In my recent study (unpublished) the administration of 10 mg nebulised salbutamol to twenty-one healthy volunteers produced profound falls in serum potassium, ranging from 0-3 to 1-4 mmot/1, within 20 min. Large falls in serum phosphate1 and calcium were seen also. Salbutamol may thus cause an important hypokalaemia.
Department of Medicine, Royal Victoria Infirmary, Newcastle upon Tyne NE1
Salbutamol may cross the blood-brain barrier: salbutamol-induced
psychosis has been seenand the drug has been found to have a quick-acting antidepressant effect,3 which has been attributed to
M. F. MYSZOR 4LP
J. REES
SW, Maglinte DDT, Lehman GA, et al. Esophageal food impaction: with glucagon. Radiology 1983, 149: 401-03. 2 Baraka A, Bikhazi G. Oesophageal foreign bodies. Br Med J 1975; i. 561-63 3. Webb WA, McDaniel L. Endoscopic evaluation of dysphagia in 293 patients with benign disease. Surg Gynecol Obstet 1984; 158: 152-56. 4. Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases Br JSurg 1. Trenkner
treatment
1978; 65: 5-9.
IMPEDANCE CARDIOGRAPHY IN HEART FAILURE
SIR,-Dr Kong and colleagues (July 19, p 170) have used impedance cardiography as a non-invasive method of measuring cardiac output in vasovagal syncope. We have investigated patients in cardiac failure by impedance cardiography and have observed a characteristic diastolic wave form. Electrical impedance changes within the thorax during the cardiac cycle (see figure) are recorded from four strip electrodes applied to the chest.! Stroke volume can be estimated from the size of the systolic wave form.2 30 patients with clinical evidence of left or right sided heart failure were investigated (mean age 63 years) and the recordings were compared with those from 30 patients with no evidence of cardiac disease (mean age 70 years). Patients were investigated supine and again with their legs elevated to 45 degrees. A diastolic wave, defmed as a deflection above the baseline, was seen in 29 patients with cardiac failure, but in only 3 controls. The abnormal wave form was augmented by leg raising because of enhanced venous return.
being small. The denominators are lower for the multiparous women with no child loss; multiparous women are more likely to have experienced a child loss. Note the denominators in the combined hospital census data: numbers
Child loss Yes No
With
Parity
Shows simultaneous recording of the first derivative of the impedance change (dz/dt) and electrocardiogram (ECG). The 1 S2s-’ standard (A), the maximum dz/dt (B), and the abnormal diastolic wave (0) are marked.
An abnormal diastolic wave has been demonstrated in patients with acute myocardial infarction and was associated with a poor prognosisIn patients with heart failure this may represent the abnormal accumulation of blood within the thorax because of raised ventricular end-diastolic pressures. This simple non-invasive technique may be useful in the diagnosis and management of patients with cardiac failure. National Heart Hospital, London W1
W. N. HUBBARD
National Hospital for Nervous Diseases, London WC1 3BG
D. R. FISH
Worthing General Hospital, Worthing, Sussex
D.
J. MCBRIEN
WN, Fish DR, McBrien DJ. The use of impedance cardiography in heart failure. Int J Cardiol 1986; 12: 71-79 Kubicek WG, Kottke FJ, Ramos MU, et al. The Minnesota impedance cardiograph: Theory and applications. Biomed Engin 1974; 9: 410-16. Ramos MU An abnormal early diastolic impedance waveform. a predictor of poor prognosis m the cardiac patient? Am Heart J 1977; 94: 274-81.
2 3
LITERACY, PARITY, FAMILY PLANNING, AND MATERNAL MORTALITY IN THE THIRD WORLD SIR,-Harrison, Rossiter, and Tan have challenged the statements of Rosenfield and Mainez about an association of high parity and matemal mortality. The data they present are interesting, but they do not refute the Rosenfield and Maine hypothesis, due to insufficient sample size and the analytical approach chosen. Perhaps more importantly, they express unsupported conclusions concerning acceptabiiity of contraception. The mortality data presented show no significant differences, the
Parzty >_
7
703 63
such as maternal mortality, analysis might be case-control improved by design. Confounding variables such as age should not be ignored, even in a brief analysis. Also, in studies of child and infant mortality, increases in mortality have been noted after the second or third birth.4 Therefore, it might have been more interesting to see maternal mortality grouped as parity 1, 2 and 3, and 4 or more. As Harrison et al say, the numbers are too small in the no child loss group to draw conclusions. Harrison et al state that "given the choice, women who will readily opt for family planning are those whose children from previous births are all likely to survive" and that "women who are not assured of the survival of their children will be most reluctant to practise effective contraception". These statements, based on the long-refuted child-replacement theory,3 do not hold up under the test of availability of family-planning services. Northern Nigeria has few sites that offer family planning and it is not clear from their letter whether Harrison et al offer such a service, let alone provide it in a fully accessible manner. In a study in Kenya, a country equally if not better known for its high fertility rate and high desired family size, we found no difference in contraceptive prevalence among non-pregnant women who either had or had not experienced a child loss. When we combined the data from four rural project areas we found: a
No 990 1886
Current contraceptzve 12-2% 11 7%
use
Clearly, there is no significant difference, hence the experience of child loss does not have the impact stated in Harrison and colleagues’ letter. Harrison et al have contributed a great deal to knowledge of maternal mortality. However, conclusions about maternal mortality and acceptance of family planning by different subgroups of the population might be improved if based on data gathered in areas of ready service provision and analysed with epidemiological techniques appropriate to the data. Department of Population Dynamics, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA
MIRIAM H. LABBOK
1. Harrison
KA, Rossiter CE, Tan H. Family planning and maternal mortality m the Third World. Lancet 1986; i: 1441. 2. Rosenfield AL, Maine D. Maternal mortality: a neglected tragedy. Lancet 1985; ii: 83-85. 4. Preston S, ed. The effects of infant and child mortality on fertility. New York: Academic Press, 1977. 3. Maine D. Family planning: its impact on the health of women and children. Center for Population and Family Health, 1981.
**This letter has been shown to Professor Harrison, whose reply to correspondence follows.-ED. L. Dr Labbok, it might help if, with Nigeria as SIR,-In an example, I point out how living conditions favour high parity and why what was said about the acceptance of contraception in relation to child loss is not as farfetched as it may seem. Poverty is widespread. Few can afford a pension and children have to provide for their parents in old age. Thus most couples have many children, hoping that some of those who survive will be sufficiently affluent to support their aged parents and others within the extended family system. In Lagos family planning has not altered family formation it and
1 Hubbard
6
a rare event
Child loss Yes No
Tracings from control patient and from patient in left-ventricular failure (LVF).
<
1614 1709
to
earlier
answer to
patterns: "the desire to have more children is even stronger than the desire to replace previous dead children", with 60% of the couples wanting more than 7 children.In Zaria the scale of child loss was such that among women of very high parity (7-24) the average number of children alive at each delivery was constant, at around 5. It is difficult to see how a lasting reduction in high parity can be achieved through family planning without concomitant development in the economic, educational, and health sectors.
866 Similar conclusions apply to reducing maternal mortality. Labbok’s analysis of data on contraceptive use in Kenya did not take account of the prevalence of contraceptive use in women with varying proportions of child loss from previous births. Furthermore, the pattern of contraceptive use found in the Kenyan villages may reflect not merely the availability of family planning per se but the introduction of other factors, operating at the same time and bringing about a change in behaviour. Dr Walker (July 19, p 162), uses information on trends in literacy and maternal mortality rates in England and Wales to argue that to reduce maternal mortality, establishing effective medical measures is more important than improving socioeconomic status. By 1880 in England and Wales maternal mortality was 5 per 1000 live births, which is comparable with the rate today in much of the third world, and the literacy rate was already over 70 %. Yet, it was not until the mid-1930s that the high maternal mortality rate began its sharp fall. According to Walker, this drop coincided with the establishment of effective obstetric care (blood banks, blood transfusion, antibiotics, and the proper management of hypertensive disease of pregnancy). ’ Walker seems to imply that this trend in England and Wales proves that, if maternal deaths are to be reduced in the third world, we must strengthen medical care delivery systems, including family planning, at the expense of socioeconomic development, especially universal formal education. Walker fails to take into account the fact that the technological developments he cites (and others he did not mention) were themselves consequent on a high literacy rate. Fortunately for the third world, and unlike the position in England and Wales in the 1880s all this knowledge is now available. What is lacking is its wide application. The eradication of mass illiteracy will not only achieve this but also will form the basis for all other developments that are essential if high maternal death rates are to fall. Knowledge through formal education facilitates, for example, the setting up of health care delivery systems and the building and maintenance of essential infrastructure; it encourages self-reliance; it is a very potent instrument for changing people’s attitudes and life-styles; and it fosters political stability and helps to achieve better spread of resources.
There are places in the third world where the medical facilities listed by Walker are available, yet women die needlessly because they cannot make full use of what is there (eg, they cannot afford transportation costs and hospital charges). Walker’s statements do not apply to the poor areas of black Africa about which I can speak from personal experience. Walker feels that because the Zaria data are from a self-selected hospital population, conclusions about maternal mortality by age and parity are suspect. However, the Zaria results are in full accord with population-based studies in showing that pregnancy in older, highly parous women carries greatly increased risks. The relation between the frequencies of twin and triplet pregnancies in booked women followed the pattern expected in population studies.2 ,
Department of Obstetrics and Gynaecology, University of Port Harcourt, PMB 5323, Port Harcourt, Nigeria
K. A. HARRISON
family formation objectives and behaviour, Shomolu, Lagos. Nigerian Med J 1983; 13: 51-56. Harrison KA. Child-bearing, health and social priorities. Br J Obstet Gynaecol 1985; suppl 5: 25-31, 46-60, 100-115.
1. Ekunwe EO. Effect of infant mortality on 2
SALBUTAMOL FOR PERTUSSIS
direct stimulation of central beta-receptors. These potential adverse effects of salbutamol serve to remind us that until a controlled double-blind trial is undertakenthe benefits of salbutamol in pertussis must be evaluated against the potential risks. 4
Poplar Drive, High Beaches, Banstead, Surrey
C. J. BUSHE
CJ. Profound hypophosphataemia in patients collapsing after a "fun run". Br Med J 1986; 292: 898-99. 2. Khanna PB, Davies R. Hallucinations associated with the administration of salbutamol via a nebuliser. Br Med J 1986; 292: 1430. 3. Simon P, Leambier Y, Jouvent K, Pueck A, Allilaire J, Widlocher D. Experimental and clinical evidence of the anti-depressant effect of a beta-adrenergic stimulant. Psychol Med 1978; 8: 335-38. 4. Broomhall J, Herxheimer A. Treatment of whooping cough: the facts. Arch Dis Child 1. Bushe
1984; 59: 185-87.
CHOPSTICKS DYSPHAGIA
SIR,-Sudden and absolute dysphagia is a distressing and serious symptom and may happen in previously healthy people. A 38-year-old man presented as an emergency with absolute dysphagia. 2 days previously, he had noticed sudden onset of severe chest pain whilst eating. The pain subsided but he could not swallow liquids or solids. His wife noticed unusual and severe halitosis. Chest X-rays, including lateral views, were normal. Endoscopy revealed abundant putrifying food debris from the midoesophagus downwards. The debris resembled liver. A small amount of debris was removed and the gastroscope was passed beyond the obstruction, which extended from mid to lower oesophagus (20-30 cm from the incisors). There was no evidence of stricture or external compression of the oesophagus. The patient was then able to swallow normally. Endoscopy on the following day revealed a normal, clear oesophagus with some oedema at 25 cm. Barium swallow was normal. At the time of the acute onset, the patient had been hurriedly eating a Chinese meal with chopsticks, and he recalled having had difficulty in swallowing a leathery piece of liver. He remains well on follow-up. A 34-year-old housewife was eating beef with chopsticks. The beef was tough and a large piece was swallowed with difficulty. Following this she experienced central chest pain and absolute dysphagia. She was seen in hospital two hours later. A chest X-ray was normal. Endoscopy revealed a large piece of beef at 28 cm with saliva above. The bolus was partly removed with forceps and the obstruction was cleared with the gastroscope. Endoscopy and barium swallow were normal. Impaction of food in the normal oesophagus is unusual. Meat is commonly implicated but in most cases the obstruction occurs in an abnormal oesophagus 1,2 as a result of narrowing due to strictures or rings,3which must be excluded by subsequent investigations. No pathological cause was found for the food impaction in these two patients. We suggest that they suffered the consequences of eating inadequately prepared food with chopsticks. With a knife and fork food can be cut up into pieces small enough to swallow easily. Someone inexperienced in the use of chopsticks, which cannot cut, may attempt to swallow a large piece of meat which they would have cut up had they been using a knife and fork. One of the largest studies of foreign bodies within the oesophagus has been reported from Hong Kong.4 We would thus advise caution when eating or preparing food that is to be consumed with the aid of
chopsticks.
SiR,—The debate about the value of salbutamol in infants with pertussis has produced from Dr Brunskill and Dr Langdon the
We thank Prof K. G. M. M. Alberti and Dr S. Proctor for permission to report these two patients.
suggestion that salbutamol has few adverse effects. In my recent study (unpublished) the administration of 10 mg nebulised salbutamol to twenty-one healthy volunteers produced profound falls in serum potassium, ranging from 0-3 to 1-4 mmot/1, within 20 min. Large falls in serum phosphate1 and calcium were seen also. Salbutamol may thus cause an important hypokalaemia.
Department of Medicine, Royal Victoria Infirmary, Newcastle upon Tyne NE1
Salbutamol may cross the blood-brain barrier: salbutamol-induced
psychosis has been seenand the drug has been found to have a quick-acting antidepressant effect,3 which has been attributed to
M. F. MYSZOR 4LP
J. REES
SW, Maglinte DDT, Lehman GA, et al. Esophageal food impaction: with glucagon. Radiology 1983, 149: 401-03. 2 Baraka A, Bikhazi G. Oesophageal foreign bodies. Br Med J 1975; i. 561-63 3. Webb WA, McDaniel L. Endoscopic evaluation of dysphagia in 293 patients with benign disease. Surg Gynecol Obstet 1984; 158: 152-56. 4. Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases Br JSurg 1. Trenkner
treatment
1978; 65: 5-9.