- Email: [email protected]
NEUROLOGICAL MANIFESTATIONS OF ACUTE HAEMORRHAGIC CONJUNCTIVITIS
528 In our survey, handicaps are classified as spasticity, retrolental fibroplasia, retardation, hearing defects, hydrocephaly, major
neurological abnormalities other than spasticity, and retardation. Mild cases of retrolental fibroplasia, hearing defects, and normally functioning hydrocephalic children are included. This means
that children who
are
able
to
lead
a
normal life with
a
mild
handicap are classified as handicapped. In 1965, basic neonatal care was started with intravenous glucose infusions, improved temperature control, early feeding TABLE I-VLBW INFANTS
(501-150 Ig) BORN AT WILHELMINA GASTHUSIS
programmes, and the beginning of artificial ventilation. These resulted in a decrease in mortality and morbidity (table I). In 1970, neonatal intensive care was introduced with artificial endotracheal umbilical vessel intubation, ventilation, catheterisation, and exchange transfusion. These methods were also used for babies weighing less than 1500 g. From 1970 to 1974 there were increases in the incidences of retrolental fibroplasia and hydrocephaly (table II). There was also a slight increase in the handicap rate during this period. After 1975 new methods became available which we used routinely on VLBW infants. Antepartum corticosteroids were
measures
TABLE 11-HANDICAPS AND NEONATAL MORTALITY IN VLBW INFANTS
given in combination with a short period of tocolysis, careful clinical observation and fetal monitoring were carried out during labour, and caesarean section was performed more frequently on mothers of VLBW infants. These measures improved the overall condition of the newborn infant. Continuous positive airways pressure using nasal prongs, Parenteral feeding via small scalp vein needles, phototherapy and transcutaneous p02 measurements, procedures carried out in a neonatal intensive care centre, have produced a further decrease in mortality and morbidity (table u). Figures for infants referred to us are also given. Data interpretation is difficult if this group is included with those born in our
NEUROLOGICAL MANIFESTATIONS OF ACUTE HAEMORRHAGIC CONJUNCTIVITIS
SiR,-In 1971 we drew attention to the polio-like neurological manifestations1,2 of "acute haemorrhagic conjunctivitis". 3 Subsequently, The Lancet, whilst admitting that it was an cautioned that, since no neurological important problem, complications had been reported outside India, more work was this aspect. However, our clinical observations were in supported three ways. (1) Kono et al.4 isolated a new enterovirus, EX 70, from the conjunctiva of Japanese patients with similar conjunctivitis and showed its neurovirulence in (2) In collaboration with Kono and his colleagueswe demonstrated in the sera of our patients significant neutralising antibody titres against EV 70, proving that the same virus was responsible for the disease in India and Japan. (3) Case reports of exactly similar neurological 7 cases soon appeared from Thailand, Taiwan, and Senegal. In India, sporadic cases and small localised outbreaks of the conjunctivitis occurring throughout the seventies did not bring a fresh crop of neurological cases, though isolated ones may have gone unnoticed. But, since early May, an epidemic of conjunctivitis has spread throughout India, and neurological cases have appeared in its wake. In 10-11 weeks we alone have seen 27 new cases. The average latent period between conjunctivitis and the neurological disorder is shorter this time (5 days only). Two main forms of the disease have been seen. 13 patients had "lumbosacral unilateral facial nerve palsy. radiculomyelitis" and 11 had 3 others had both. The radiculomyelitis consists of a hypotonic, areflexic, asymmetrical paralysis of the lower limbs, which tends to be proximal and is often preceded by bilateral sciatica or muscular pains. The upper limbs may or may not be affected. This time there has been a much greater incidence of facial palsy, initially misdiagnosed and referred to us as Bell’s palsy. The close relation to the conjunctivitis, the preceding fever and malaise, the occasional association with vertigo (without deafness), the cerebrospinal-fluid pleocytosis and the electromyographic localisation of the lesion in the facial nucleus or proximal part of the nerve clearly differentiated between the two conditions. Besides these common presentations, we have seen cases of isolated cranial nerve palsy. Here we cannot yet be certain of a causal association. One baby aged 9 months, with encephalitis (periodic complexes in the EEG) closely preceded by conjunctivitis, had been in close contact with 6 adults with conjunctivitis. Finally, we have learned of a case at the J. J. Hospital in which a patient who had conjunctivitis died a fortnight later from respiratory paralysis after an illness resembling acute ascending transverse myelitis. This could be the first death reported in this disease. We write this mid-investigation report to draw urgent attention to the crippling sequelae of this so-called benign virus. Follow-up of our 1971 patients and experience of others has shown that nearly two-thirds of the neurologically afflicted patients remain permanently handicapped. The incidence of acute haemorrhagic conjunctivitis is very hard to assess, but a figure of 15 to 20 million alone in India during this epidemic would be perhaps an underestimate. Accepting as reasonable the figures reported from Taiwanof one neurological case per 10 000 patients with conjunctivitis, we feel that several thousand persons have been crippled all over the world in the last decade by this virus. needed
on
monkeys.s
isolated,
hospital.
cases of retrolental fibroplasia occurred in the referrals, indicating that better control of p02 is achieved in the non-referrals.
Most
From 1959 there has been a decrease in mortality and morbidity. From 1970 to 1975, after the start of neonatal intensive care, there was a slight increase in the handicap rate, but a striking decrease in morbidity and mortality has occurred during subsequent years. We thank Prof. Dr G. J. Kloosterman, Dr R. de Leeuw, Dr A. MarinkovicIlsen, Mr G. J. M. Peters, Dr H. Smolders-de Haas, and Dr S. Soepatmi.
1 Wadia NH, Urani PF, Katrak SM. Neurological complications of anew conjunctivitis, Lancet 1972, ii: 970-1 2. Wadia NH, Irani PF, Katrak SM. Lumbosacral radiculomyelitis associated with pandemic acute haemorrhagic conjunctivitis, Lancet 1973; i 350-52 3. Editorial. Acute haemorrhagic conjunctivitis. Lancet 1973; i: 86-7 4. Kono R, Sasagawa A, Ishii K, et al. Pandemic of new type of conjunctivitis. Lancet 1972; i: 1191-4 5 Kono R, Uchida N, Sasagawa A, et al. Neurovirulance of acute haemorrhagic
Departments of Neonatology and Obstetrics, Wilhelmina Gasthuis University 1054 EG Amsterdam,
Netherlands
7.
Hospital,
J. G. KOPPE P. E. TREFFERS
conjunctivitis virus in monkeys Lancet 1973; i: 61-3 R, Miyamura K, Tajiri E, et al Neurologic complications associated with acute haemorrhagic conjunctivitis virus infection and its serologic confirmation J Inject Dis 1974; 129: 590-93 Hung TP, Kono R Neurological complications of acute haemorrhagic conjunctivitis (A polio-like syndrome in adults) In: Vinken PJ, Bruyn GW, Klawans HL, eds Handbook of clinical neurology, vol 38 Amsterdam: North Holland, 1979
6. Kono
595-623
529 A word of caution. We feel that, as in classic poliomyelitis, intramuscular injections may precipitate paralysis. We advise bed rest and avoidance of injections during the conjunctivitis and at the onset of malaise preceding the neurological disease. Similarly, we avoid electromyography in the acute and developing phase of the disease. If, as we suppose, this disease is due to a single enterovirus, is it not time that W.H.O and international virologists got together to develop a vaccine to stamp it out and limit the neurological disaster which is already in progress?
N. H. WADIA P. N. WADIA S. M. KATRAK V. P. MISRA
Departments of Neurology, Sir J J Group of Hospitals and the Jaslok Hospital and Research Centre, Bombay, India
HEADACHE AFTER LUMBAR PUNCTURE
SIR,-As the discussion continues, the preponderance of evidence points to a major role for psychological factors. It may be relevant that headache virtually never follows lumbar puncture in children, particularly those under ten years of age. We have done lumbar punctures in all newly diagnosed cases of acute leukaemia since 1960 and have administered intrathecal therapy to hundreds of children since 1965. It is typical for the children to sit up immediately afterwards and to walk back to their rooms without complaint. Outpatients receive their intrathecal medications, walk out, and go home without subsequent complaints. Perhaps the anatomy and physiology of the child differs but I suspect that the children’s behaviour is itself a message. Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital,
DONALDJ.FERNBACH
Houston, Texas 77030, U.S.A.
LEYDIG CELL DYSFUNCTION AFTER COMBINATION CHEMOTHERAPY
SIR,-Dr Graner (July 4, p. 41) says that "most studies of patients receiving alkylating agents show normal serum luteinising hormone (LH) and testosterone (T) levels". In our study of 15 postpubertal males after combination chemotherapy (including an alkylating agent) for malignant lymphoma, basal serum LH was raised in 7 men. In 4 of these subjects serial basal LH showed a progressive rise with chemotherapy. This rise in LH was accompanied by exaggerated LH response to luteinising hormone releasing hormone (LHRH). In addition, basal serum T was below the normal range in 2 out of the 15 subjects. Serial samples showed a progressive depression of circulating T with each course of chemotherapy. Our findings together with previous studies2-4 suggest that, although the Leydig cells remain histologically normal in men after similar regimens of chemotherapy,S,6 Leydig cell dysfunction is evident from the frequent occurrence of depressed basal T and elevated basal LH levels and the exaggerated LH
LABORATORY SCREENING FOR PHYSICAL ILLNESS IN PSYCHIATRIC PATIENTS
SIR,-It has been suggested that psychiatric outpatients should be screened routinely for physical illness by laboratory investigation.! Blood count, red cell diameter, blood vitamins, blood glucose, syphilis serology, thyroid function, liver function, blood urea, electrolytes and calcium, chest and skull radiography, and urinalysis were proposed as suitable screening tests. However, whilst psychiatrists recognise the need to carry out these ancillary investigations when clinically indicated in individual patients, many would consider that it is unwarranted to use these tests routinely for all patients I have surveyed current practice among consultants in general adult psychiatry and among academic staff with consultant clinical responsibility in the United Kingdom. They were identified from the 1977 membership list of the Royal College of Psychiatrists and the 1980 Medical Directory. 10% of these consultants, selected at random, were sent a questionnaire in which they were asked to identify those investigations which they ordered routinely for all or most of their patients. General psychiatric inpatients, psychogeriatric patients, and general psychiatric outpatients were considered separately. The response rate was 100 (90%) of the 111I psychiatrists contacted. There was wide variation between psychiatrists in the number of routine investigations for their hospital patients. 14% of the respondents indicated that they did not carry out any investigations routinely, while others reported they used up to fifteen routine tests. Specialist psychogeriatricians were excluded from the survey, but 62% of the respondents said they were involved in the assessment of psychogeriatric patients. The responses suggested that these patients were investigated more intensively than general psychiatric patients; two-thirds of these psychiatrists ordered more than six routine investigations for psychogeriatric patients, while a similar proportion of respondents ordered six or fewer investigations for general psychiatric patients. However, there is still great variation in the extent to which psychogeriatric patients are investigated; 3 (5%) of the respondents reported that they ordered no routine investigations while others used up to fifteen
(table). PERCENTAGE OF PSYCHIATRISTS USING TEST ROUTINELY
responses to LHRH. CHRISTINA WANG
RONALD P. NG T. K. CHAN DAVID TODD
Department of Medicine, Queen Mary’s Hospital, Hong Kong
1 Wang C, Ng RP, Chan TK, Todd D. Effect of combination chemotherapy on pituitarygonadal function in patients with lymphoma and leukemia. Cancer 1980; 45: 2030-37 2
MechlenburgRS, Sherins RJ. Gonadotropinresponse toluteinizing hormone releasing hormone in men with germinal aplasia. J Clin Endocrinol Metabol 1974; 38: 1005-09.
3 Jacobson RJ, SagelJ, Distiller LA, Morley JE Leydig cell dysfunction in male patients with Hodgkin’s disease receiving chemotherapy Clin Res 1978; 26: 437 (A). 4 Glode LM, Robinson J, Gould SF. Protection from cyclophosphamide induced testicular damage with 1981; i.1132-34
an
analogue of gonadotropin-releasing hormone. Lancet
Lewis BJ, Sherins RJ, Young RC Gonadal dysfunction in patients receiving chemotherapy for cancer. Ann Intern Med 1980; 93: 109-14. 5 Sherins RJ, DeVita VT Jr. Effects of drug treatment for lymphoma on male reproductive capacity: studies of men in remission after therapy. Ann Intern Med
5 Schilsky RJ,
1973, 79: 216-20
The most popular screening tests used in general psychiatry reflect those commonly used in general medicine rather than any specific needs of clinical psychiatry. Syphilis serology is an exception, and may owe its continued popularity to the historical importance of neurosyphilis, which is now rare in psychiatric practice.2 In contrast, tests of thyroid function, vitamin BI2’ and folate levels, abnormalities of which are apparently now more common than neurosyphilis as causes of psychiatric morbidity,3>4 1. Editorial. Psychiatrists with blinkers. Lancet 1979; ii: 81. 2. Dewhurst K. The neurosyphilitic psychoses today. Br J Psychiatry 1969; 115: 31-38.
Whybrow PC, Prange AJ, Treadway CR. Mental changes accompanying thyroid gland dysfunction. Arch Gen Psychiatry 1969; 20: 48-63 4. Shorvon SD, Carney MWP, Chanarin I, Reynolds EH. The neuropsychiatry of megaloblastic anaemia. Br Med J 1980; 281: 1036-38. 3.
neurological abnormalities other than spasticity, and retardation. Mild cases of retrolental fibroplasia, hearing defects, and normally functioning hydrocephalic children are included. This means
that children who
are
able
to
lead
a
normal life with
a
mild
handicap are classified as handicapped. In 1965, basic neonatal care was started with intravenous glucose infusions, improved temperature control, early feeding TABLE I-VLBW INFANTS
(501-150 Ig) BORN AT WILHELMINA GASTHUSIS
programmes, and the beginning of artificial ventilation. These resulted in a decrease in mortality and morbidity (table I). In 1970, neonatal intensive care was introduced with artificial endotracheal umbilical vessel intubation, ventilation, catheterisation, and exchange transfusion. These methods were also used for babies weighing less than 1500 g. From 1970 to 1974 there were increases in the incidences of retrolental fibroplasia and hydrocephaly (table II). There was also a slight increase in the handicap rate during this period. After 1975 new methods became available which we used routinely on VLBW infants. Antepartum corticosteroids were
measures
TABLE 11-HANDICAPS AND NEONATAL MORTALITY IN VLBW INFANTS
given in combination with a short period of tocolysis, careful clinical observation and fetal monitoring were carried out during labour, and caesarean section was performed more frequently on mothers of VLBW infants. These measures improved the overall condition of the newborn infant. Continuous positive airways pressure using nasal prongs, Parenteral feeding via small scalp vein needles, phototherapy and transcutaneous p02 measurements, procedures carried out in a neonatal intensive care centre, have produced a further decrease in mortality and morbidity (table u). Figures for infants referred to us are also given. Data interpretation is difficult if this group is included with those born in our
NEUROLOGICAL MANIFESTATIONS OF ACUTE HAEMORRHAGIC CONJUNCTIVITIS
SiR,-In 1971 we drew attention to the polio-like neurological manifestations1,2 of "acute haemorrhagic conjunctivitis". 3 Subsequently, The Lancet, whilst admitting that it was an cautioned that, since no neurological important problem, complications had been reported outside India, more work was this aspect. However, our clinical observations were in supported three ways. (1) Kono et al.4 isolated a new enterovirus, EX 70, from the conjunctiva of Japanese patients with similar conjunctivitis and showed its neurovirulence in (2) In collaboration with Kono and his colleagueswe demonstrated in the sera of our patients significant neutralising antibody titres against EV 70, proving that the same virus was responsible for the disease in India and Japan. (3) Case reports of exactly similar neurological 7 cases soon appeared from Thailand, Taiwan, and Senegal. In India, sporadic cases and small localised outbreaks of the conjunctivitis occurring throughout the seventies did not bring a fresh crop of neurological cases, though isolated ones may have gone unnoticed. But, since early May, an epidemic of conjunctivitis has spread throughout India, and neurological cases have appeared in its wake. In 10-11 weeks we alone have seen 27 new cases. The average latent period between conjunctivitis and the neurological disorder is shorter this time (5 days only). Two main forms of the disease have been seen. 13 patients had "lumbosacral unilateral facial nerve palsy. radiculomyelitis" and 11 had 3 others had both. The radiculomyelitis consists of a hypotonic, areflexic, asymmetrical paralysis of the lower limbs, which tends to be proximal and is often preceded by bilateral sciatica or muscular pains. The upper limbs may or may not be affected. This time there has been a much greater incidence of facial palsy, initially misdiagnosed and referred to us as Bell’s palsy. The close relation to the conjunctivitis, the preceding fever and malaise, the occasional association with vertigo (without deafness), the cerebrospinal-fluid pleocytosis and the electromyographic localisation of the lesion in the facial nucleus or proximal part of the nerve clearly differentiated between the two conditions. Besides these common presentations, we have seen cases of isolated cranial nerve palsy. Here we cannot yet be certain of a causal association. One baby aged 9 months, with encephalitis (periodic complexes in the EEG) closely preceded by conjunctivitis, had been in close contact with 6 adults with conjunctivitis. Finally, we have learned of a case at the J. J. Hospital in which a patient who had conjunctivitis died a fortnight later from respiratory paralysis after an illness resembling acute ascending transverse myelitis. This could be the first death reported in this disease. We write this mid-investigation report to draw urgent attention to the crippling sequelae of this so-called benign virus. Follow-up of our 1971 patients and experience of others has shown that nearly two-thirds of the neurologically afflicted patients remain permanently handicapped. The incidence of acute haemorrhagic conjunctivitis is very hard to assess, but a figure of 15 to 20 million alone in India during this epidemic would be perhaps an underestimate. Accepting as reasonable the figures reported from Taiwanof one neurological case per 10 000 patients with conjunctivitis, we feel that several thousand persons have been crippled all over the world in the last decade by this virus. needed
on
monkeys.s
isolated,
hospital.
cases of retrolental fibroplasia occurred in the referrals, indicating that better control of p02 is achieved in the non-referrals.
Most
From 1959 there has been a decrease in mortality and morbidity. From 1970 to 1975, after the start of neonatal intensive care, there was a slight increase in the handicap rate, but a striking decrease in morbidity and mortality has occurred during subsequent years. We thank Prof. Dr G. J. Kloosterman, Dr R. de Leeuw, Dr A. MarinkovicIlsen, Mr G. J. M. Peters, Dr H. Smolders-de Haas, and Dr S. Soepatmi.
1 Wadia NH, Urani PF, Katrak SM. Neurological complications of anew conjunctivitis, Lancet 1972, ii: 970-1 2. Wadia NH, Irani PF, Katrak SM. Lumbosacral radiculomyelitis associated with pandemic acute haemorrhagic conjunctivitis, Lancet 1973; i 350-52 3. Editorial. Acute haemorrhagic conjunctivitis. Lancet 1973; i: 86-7 4. Kono R, Sasagawa A, Ishii K, et al. Pandemic of new type of conjunctivitis. Lancet 1972; i: 1191-4 5 Kono R, Uchida N, Sasagawa A, et al. Neurovirulance of acute haemorrhagic
Departments of Neonatology and Obstetrics, Wilhelmina Gasthuis University 1054 EG Amsterdam,
Netherlands
7.
Hospital,
J. G. KOPPE P. E. TREFFERS
conjunctivitis virus in monkeys Lancet 1973; i: 61-3 R, Miyamura K, Tajiri E, et al Neurologic complications associated with acute haemorrhagic conjunctivitis virus infection and its serologic confirmation J Inject Dis 1974; 129: 590-93 Hung TP, Kono R Neurological complications of acute haemorrhagic conjunctivitis (A polio-like syndrome in adults) In: Vinken PJ, Bruyn GW, Klawans HL, eds Handbook of clinical neurology, vol 38 Amsterdam: North Holland, 1979
6. Kono
595-623
529 A word of caution. We feel that, as in classic poliomyelitis, intramuscular injections may precipitate paralysis. We advise bed rest and avoidance of injections during the conjunctivitis and at the onset of malaise preceding the neurological disease. Similarly, we avoid electromyography in the acute and developing phase of the disease. If, as we suppose, this disease is due to a single enterovirus, is it not time that W.H.O and international virologists got together to develop a vaccine to stamp it out and limit the neurological disaster which is already in progress?
N. H. WADIA P. N. WADIA S. M. KATRAK V. P. MISRA
Departments of Neurology, Sir J J Group of Hospitals and the Jaslok Hospital and Research Centre, Bombay, India
HEADACHE AFTER LUMBAR PUNCTURE
SIR,-As the discussion continues, the preponderance of evidence points to a major role for psychological factors. It may be relevant that headache virtually never follows lumbar puncture in children, particularly those under ten years of age. We have done lumbar punctures in all newly diagnosed cases of acute leukaemia since 1960 and have administered intrathecal therapy to hundreds of children since 1965. It is typical for the children to sit up immediately afterwards and to walk back to their rooms without complaint. Outpatients receive their intrathecal medications, walk out, and go home without subsequent complaints. Perhaps the anatomy and physiology of the child differs but I suspect that the children’s behaviour is itself a message. Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital,
DONALDJ.FERNBACH
Houston, Texas 77030, U.S.A.
LEYDIG CELL DYSFUNCTION AFTER COMBINATION CHEMOTHERAPY
SIR,-Dr Graner (July 4, p. 41) says that "most studies of patients receiving alkylating agents show normal serum luteinising hormone (LH) and testosterone (T) levels". In our study of 15 postpubertal males after combination chemotherapy (including an alkylating agent) for malignant lymphoma, basal serum LH was raised in 7 men. In 4 of these subjects serial basal LH showed a progressive rise with chemotherapy. This rise in LH was accompanied by exaggerated LH response to luteinising hormone releasing hormone (LHRH). In addition, basal serum T was below the normal range in 2 out of the 15 subjects. Serial samples showed a progressive depression of circulating T with each course of chemotherapy. Our findings together with previous studies2-4 suggest that, although the Leydig cells remain histologically normal in men after similar regimens of chemotherapy,S,6 Leydig cell dysfunction is evident from the frequent occurrence of depressed basal T and elevated basal LH levels and the exaggerated LH
LABORATORY SCREENING FOR PHYSICAL ILLNESS IN PSYCHIATRIC PATIENTS
SIR,-It has been suggested that psychiatric outpatients should be screened routinely for physical illness by laboratory investigation.! Blood count, red cell diameter, blood vitamins, blood glucose, syphilis serology, thyroid function, liver function, blood urea, electrolytes and calcium, chest and skull radiography, and urinalysis were proposed as suitable screening tests. However, whilst psychiatrists recognise the need to carry out these ancillary investigations when clinically indicated in individual patients, many would consider that it is unwarranted to use these tests routinely for all patients I have surveyed current practice among consultants in general adult psychiatry and among academic staff with consultant clinical responsibility in the United Kingdom. They were identified from the 1977 membership list of the Royal College of Psychiatrists and the 1980 Medical Directory. 10% of these consultants, selected at random, were sent a questionnaire in which they were asked to identify those investigations which they ordered routinely for all or most of their patients. General psychiatric inpatients, psychogeriatric patients, and general psychiatric outpatients were considered separately. The response rate was 100 (90%) of the 111I psychiatrists contacted. There was wide variation between psychiatrists in the number of routine investigations for their hospital patients. 14% of the respondents indicated that they did not carry out any investigations routinely, while others reported they used up to fifteen routine tests. Specialist psychogeriatricians were excluded from the survey, but 62% of the respondents said they were involved in the assessment of psychogeriatric patients. The responses suggested that these patients were investigated more intensively than general psychiatric patients; two-thirds of these psychiatrists ordered more than six routine investigations for psychogeriatric patients, while a similar proportion of respondents ordered six or fewer investigations for general psychiatric patients. However, there is still great variation in the extent to which psychogeriatric patients are investigated; 3 (5%) of the respondents reported that they ordered no routine investigations while others used up to fifteen
(table). PERCENTAGE OF PSYCHIATRISTS USING TEST ROUTINELY
responses to LHRH. CHRISTINA WANG
RONALD P. NG T. K. CHAN DAVID TODD
Department of Medicine, Queen Mary’s Hospital, Hong Kong
1 Wang C, Ng RP, Chan TK, Todd D. Effect of combination chemotherapy on pituitarygonadal function in patients with lymphoma and leukemia. Cancer 1980; 45: 2030-37 2
MechlenburgRS, Sherins RJ. Gonadotropinresponse toluteinizing hormone releasing hormone in men with germinal aplasia. J Clin Endocrinol Metabol 1974; 38: 1005-09.
3 Jacobson RJ, SagelJ, Distiller LA, Morley JE Leydig cell dysfunction in male patients with Hodgkin’s disease receiving chemotherapy Clin Res 1978; 26: 437 (A). 4 Glode LM, Robinson J, Gould SF. Protection from cyclophosphamide induced testicular damage with 1981; i.1132-34
an
analogue of gonadotropin-releasing hormone. Lancet
Lewis BJ, Sherins RJ, Young RC Gonadal dysfunction in patients receiving chemotherapy for cancer. Ann Intern Med 1980; 93: 109-14. 5 Sherins RJ, DeVita VT Jr. Effects of drug treatment for lymphoma on male reproductive capacity: studies of men in remission after therapy. Ann Intern Med
5 Schilsky RJ,
1973, 79: 216-20
The most popular screening tests used in general psychiatry reflect those commonly used in general medicine rather than any specific needs of clinical psychiatry. Syphilis serology is an exception, and may owe its continued popularity to the historical importance of neurosyphilis, which is now rare in psychiatric practice.2 In contrast, tests of thyroid function, vitamin BI2’ and folate levels, abnormalities of which are apparently now more common than neurosyphilis as causes of psychiatric morbidity,3>4 1. Editorial. Psychiatrists with blinkers. Lancet 1979; ii: 81. 2. Dewhurst K. The neurosyphilitic psychoses today. Br J Psychiatry 1969; 115: 31-38.
Whybrow PC, Prange AJ, Treadway CR. Mental changes accompanying thyroid gland dysfunction. Arch Gen Psychiatry 1969; 20: 48-63 4. Shorvon SD, Carney MWP, Chanarin I, Reynolds EH. The neuropsychiatry of megaloblastic anaemia. Br Med J 1980; 281: 1036-38. 3.