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MICTURATING CYSTOURETHROGRAPHY
105
series, antinuclear antibodies were not detected in whole cryoprecipitate, or in the supernatant. Only anti-y-globulin antibodies are firmly associated with cryoprecipitate, and this finding is consistent with the hypothesis that cryoprecipitate arises from an immunological phenomenon which is the result of the antibody activity of its IgM component against human IgG. Therefore, the findings of Kaplan and Tan are probably connected with a particular characteristic of cryoprecipitates in infectious mononucleosis
MICTURATING CYSTOURETHROGRAPHY
our
serum, in the
not present in other diseases. The antinuclear of sera may be due to the IgG infectious-mononucleosis activity component of cryoprecipitate, because the IgM component is already engaged in the anti-y-globulin activity.
which is
Istituto di Clinica Medica, University of Milan,
Milan, Italy.
D. MAZZEI C. CATTANEO C. NOVI V. SIMONATI.
ADAPTATION TO LOW-PROTEIN INTAKES SIR,-We are interested in Professor Waterlow’s observationsand should like to draw attention to published work from our laboratories which we believe to be relevant to the endocrine regulation of the adaptive mechanism in proteincalorie malnutrition (P.c.M.). Fasting plasma-growth-hormone (H.G.H.) levels, as measured by the radioimmunoassay method of Glick et al.,2 are raised in patients with P.C.M.,3 have no relationship to either the bloodglucose level or carbohydrate intake, and drop only when protein is introduced into the diet.4 The raised levels are not
normally suppressed by induced hyperglycxmia.5 H.G.H. levels correlate inversely with the plasma-albumin concentration,4 the highest H.G.H. levels usually appearing in those subjects with the lowest albumin level. Since we have evidence that the albumin level per se does not directly influence growth-hormone homaeostasis,6 the high level of the latter is probably consequent on the degree of protein depletion, of which the low plasma-albumin level is only one manifestation. The mechanism of the elevation of H.G.H. level remains obscure, but changes in the pattern or concentration of plasma-aminoacids may be relevant. 6 We must stress that there is no direct evidence that these high H.G.H. levels imply hypersecretion; impaired degradation, though less likely, might be responsible. Studies in this connection are at present in progress. In either event, the net result would be an excess of circulating H.G.H., poorly responsive to normal blood-glucose fluctuations, and dropping only after the introduction of protein. This would appear to be an important endocrine adaptive response to protein deprivation, for growth hormone spares nitrogenand stimulates both membrane aminoacid transport and protein synthesis,8 effects which are vital for the conservation of the very meagre resources of the protein-deprived individual. Departments of Medicine and Child Health, University of Cape Town Medical School, Cape Town, South Africa. 1. 2.
B. L. PIMSTONE J. D. L. HANSEN.
Waterlow, J. C. Lancet, 1968, ii, 1091. Glick, S. M., Roth, J., Yalow, R. S., Berson, S. A. Nature, Lond. 1963, 199, 784. 3. Pimstone, B. L., Wittmann, W., Hansen, J. D. L., Murray, P. Lancet, 1966, ii, 779. 4. Pimstone, B. L., Barbezat, G., Hansen, J. D. L., Murray, P. Am. J. clin. Nutr. 1968, 21, 482. 5. Pimstone, B. L., Barbezat, G., Hansen, J. D. L., Murray, P. Lancet, 1967, ii, 1333. 6. Pimstone, B. L., Saunders, S. J., Hansen, J. D. L., Murray, P. in International Symposium on Protein and Polypeptide Hormones, Liège, May, 1968. Excerpta med. vol. III. Amsterdam (in the press). 7. Henneman, P. H., Forbes, A. P., Moldawer, M., Dempsey, E. F., Carrol, E. L. J. clin. Invest. 1960, 39, 1223. 8. Korner, A., Munro, A. J. Biochem. biophys. Res. Comm. 1963, 11, 235. Korner, A. ibid. 1963, 13, 386. Kosto, J. L. Endocrinology, 1964, 75, 113.
SIR,-Few would dispute the statement by Mr. Gingell (Dec. 21, p. 1346) that micturating cystourethrography is a particularly embarrassing and unpleasant investigation in the female "-when it is performed using standard X-ray equipment which requires the radiologist to stand or sit close to the patient. It is not surprising that many patients have difficulty in initiating micturition-a more embarrassing situation is difficult to imagine. However, modern apparatus is becoming more freely available, with image intensification and television viewing suitably arranged to allow remote control of the equipment. In fact, some older apparatus can be modified without much difficulty to give these facilities (which are invaluable, not only for micturating cystourethrography, but indeed for many X-ray procedures, including barium-meal "
work and myelography). Where remote-control facilities are available the radiologist operates the apparatus from within the radiographer’s protective cubicle and is therefore some distance away from the patient. Micturating cystourethrography is carried out at the London Hospital as follows: The radiologist briefly explains to the patient what is to take place, he then leaves the room while sister fills the bladder with radio-opaque contrast medium, and when this has been done the radiologist returns and examines the patient, who at this stage is lying supine. The bladder and upper urinary tracts are screened and films taken if required. The table is then tilted to the erect position, the room lights are dimmed, and sister places the plastic receiver, into which the patient later micturates, between the patient’s legs (a length of rubber tubing connects the receiver to a bowl placed on the floor). While this is being done the radiologist and radiographer are outside the patient’s view behind the protective screen. Finally, the room lights are turned out and the patient is asked to try to micturate; if she has any difficulty the taps in the washhand basin are turned on, and this old trick often helps the patient. The radiologist follows events on the television screen; and it is very helpful to record the findings on video-tape. Radiographs are also taken as required.
In this way, with the radiologist at a distance from the patient, the patient’s embarrassment is reduced to a minimum. Moreover, this method improves the results of the examination, since patients can cooperate more readily, and it usually reduces the time taken for this valuable investigation. Radiodiagnostic Department, The London Hospital, London E.1.
R. S. MURRAY.
PRESERVATION OF LEUCOCYTES FOR DELAYED COUNTS SIR,-We are concerned with the study of certain immunological problems in relation to cardiovascular disorders in tropical environmentsand in this connection we have recently carried out a large number of leucocyte-counts in African and European subjects living in Kampala, Uganda. When one refers to reports on leucocyte patterns in tropical or isolated populations one is immediately impressed by the fact that total leucocyte-counts have frequently not been carried out or have been performed by crude and indirect methods. Our current studies suggest very strongly that the neutropenia seen in many African communities,23 in American Negro subjects,45 and in West Indian and African subjects living in England 61 may be a normal genetically determined characteristic of populations of African origin. Leucocyte studies on communities in diverse environmental situations and of varving ethnic origin, to test this possibility, would be 1. Shaper, A. G., Kaplan, M. H., Mody, N. J., McIntyre, P. A. Lancet, 2.
1968, i, 1342. Trowell, H. C.
Non-infective Disease in Africa; p. 428.
London,
1960.
Shaper, A. G., Kyobe, J., Stansfield, D. E. Afr. med. J. 1962, 39, 1. Forbes, W. H., Johnson, R. E., Consolazio, F. Am. J. med. Sci. 1941, 201, 407. 5. Broun, G. O., Herbig, F. K., Hamilton, J. R. New Engl. J. Med. 1966, 275, 1410. 6. Rippey, J. J. Lancet, 1967, ii, 44. 7. Davis, L. R. ibid. p. 213.
3. 4.
series, antinuclear antibodies were not detected in whole cryoprecipitate, or in the supernatant. Only anti-y-globulin antibodies are firmly associated with cryoprecipitate, and this finding is consistent with the hypothesis that cryoprecipitate arises from an immunological phenomenon which is the result of the antibody activity of its IgM component against human IgG. Therefore, the findings of Kaplan and Tan are probably connected with a particular characteristic of cryoprecipitates in infectious mononucleosis
MICTURATING CYSTOURETHROGRAPHY
our
serum, in the
not present in other diseases. The antinuclear of sera may be due to the IgG infectious-mononucleosis activity component of cryoprecipitate, because the IgM component is already engaged in the anti-y-globulin activity.
which is
Istituto di Clinica Medica, University of Milan,
Milan, Italy.
D. MAZZEI C. CATTANEO C. NOVI V. SIMONATI.
ADAPTATION TO LOW-PROTEIN INTAKES SIR,-We are interested in Professor Waterlow’s observationsand should like to draw attention to published work from our laboratories which we believe to be relevant to the endocrine regulation of the adaptive mechanism in proteincalorie malnutrition (P.c.M.). Fasting plasma-growth-hormone (H.G.H.) levels, as measured by the radioimmunoassay method of Glick et al.,2 are raised in patients with P.C.M.,3 have no relationship to either the bloodglucose level or carbohydrate intake, and drop only when protein is introduced into the diet.4 The raised levels are not
normally suppressed by induced hyperglycxmia.5 H.G.H. levels correlate inversely with the plasma-albumin concentration,4 the highest H.G.H. levels usually appearing in those subjects with the lowest albumin level. Since we have evidence that the albumin level per se does not directly influence growth-hormone homaeostasis,6 the high level of the latter is probably consequent on the degree of protein depletion, of which the low plasma-albumin level is only one manifestation. The mechanism of the elevation of H.G.H. level remains obscure, but changes in the pattern or concentration of plasma-aminoacids may be relevant. 6 We must stress that there is no direct evidence that these high H.G.H. levels imply hypersecretion; impaired degradation, though less likely, might be responsible. Studies in this connection are at present in progress. In either event, the net result would be an excess of circulating H.G.H., poorly responsive to normal blood-glucose fluctuations, and dropping only after the introduction of protein. This would appear to be an important endocrine adaptive response to protein deprivation, for growth hormone spares nitrogenand stimulates both membrane aminoacid transport and protein synthesis,8 effects which are vital for the conservation of the very meagre resources of the protein-deprived individual. Departments of Medicine and Child Health, University of Cape Town Medical School, Cape Town, South Africa. 1. 2.
B. L. PIMSTONE J. D. L. HANSEN.
Waterlow, J. C. Lancet, 1968, ii, 1091. Glick, S. M., Roth, J., Yalow, R. S., Berson, S. A. Nature, Lond. 1963, 199, 784. 3. Pimstone, B. L., Wittmann, W., Hansen, J. D. L., Murray, P. Lancet, 1966, ii, 779. 4. Pimstone, B. L., Barbezat, G., Hansen, J. D. L., Murray, P. Am. J. clin. Nutr. 1968, 21, 482. 5. Pimstone, B. L., Barbezat, G., Hansen, J. D. L., Murray, P. Lancet, 1967, ii, 1333. 6. Pimstone, B. L., Saunders, S. J., Hansen, J. D. L., Murray, P. in International Symposium on Protein and Polypeptide Hormones, Liège, May, 1968. Excerpta med. vol. III. Amsterdam (in the press). 7. Henneman, P. H., Forbes, A. P., Moldawer, M., Dempsey, E. F., Carrol, E. L. J. clin. Invest. 1960, 39, 1223. 8. Korner, A., Munro, A. J. Biochem. biophys. Res. Comm. 1963, 11, 235. Korner, A. ibid. 1963, 13, 386. Kosto, J. L. Endocrinology, 1964, 75, 113.
SIR,-Few would dispute the statement by Mr. Gingell (Dec. 21, p. 1346) that micturating cystourethrography is a particularly embarrassing and unpleasant investigation in the female "-when it is performed using standard X-ray equipment which requires the radiologist to stand or sit close to the patient. It is not surprising that many patients have difficulty in initiating micturition-a more embarrassing situation is difficult to imagine. However, modern apparatus is becoming more freely available, with image intensification and television viewing suitably arranged to allow remote control of the equipment. In fact, some older apparatus can be modified without much difficulty to give these facilities (which are invaluable, not only for micturating cystourethrography, but indeed for many X-ray procedures, including barium-meal "
work and myelography). Where remote-control facilities are available the radiologist operates the apparatus from within the radiographer’s protective cubicle and is therefore some distance away from the patient. Micturating cystourethrography is carried out at the London Hospital as follows: The radiologist briefly explains to the patient what is to take place, he then leaves the room while sister fills the bladder with radio-opaque contrast medium, and when this has been done the radiologist returns and examines the patient, who at this stage is lying supine. The bladder and upper urinary tracts are screened and films taken if required. The table is then tilted to the erect position, the room lights are dimmed, and sister places the plastic receiver, into which the patient later micturates, between the patient’s legs (a length of rubber tubing connects the receiver to a bowl placed on the floor). While this is being done the radiologist and radiographer are outside the patient’s view behind the protective screen. Finally, the room lights are turned out and the patient is asked to try to micturate; if she has any difficulty the taps in the washhand basin are turned on, and this old trick often helps the patient. The radiologist follows events on the television screen; and it is very helpful to record the findings on video-tape. Radiographs are also taken as required.
In this way, with the radiologist at a distance from the patient, the patient’s embarrassment is reduced to a minimum. Moreover, this method improves the results of the examination, since patients can cooperate more readily, and it usually reduces the time taken for this valuable investigation. Radiodiagnostic Department, The London Hospital, London E.1.
R. S. MURRAY.
PRESERVATION OF LEUCOCYTES FOR DELAYED COUNTS SIR,-We are concerned with the study of certain immunological problems in relation to cardiovascular disorders in tropical environmentsand in this connection we have recently carried out a large number of leucocyte-counts in African and European subjects living in Kampala, Uganda. When one refers to reports on leucocyte patterns in tropical or isolated populations one is immediately impressed by the fact that total leucocyte-counts have frequently not been carried out or have been performed by crude and indirect methods. Our current studies suggest very strongly that the neutropenia seen in many African communities,23 in American Negro subjects,45 and in West Indian and African subjects living in England 61 may be a normal genetically determined characteristic of populations of African origin. Leucocyte studies on communities in diverse environmental situations and of varving ethnic origin, to test this possibility, would be 1. Shaper, A. G., Kaplan, M. H., Mody, N. J., McIntyre, P. A. Lancet, 2.
1968, i, 1342. Trowell, H. C.
Non-infective Disease in Africa; p. 428.
London,
1960.
Shaper, A. G., Kyobe, J., Stansfield, D. E. Afr. med. J. 1962, 39, 1. Forbes, W. H., Johnson, R. E., Consolazio, F. Am. J. med. Sci. 1941, 201, 407. 5. Broun, G. O., Herbig, F. K., Hamilton, J. R. New Engl. J. Med. 1966, 275, 1410. 6. Rippey, J. J. Lancet, 1967, ii, 44. 7. Davis, L. R. ibid. p. 213.
3. 4.