- Email: [email protected]
PREMEDICATION FOR OUTPATIENT ELECTROCONVULSION THERAPY
1337
reflex arc, involving the trigeminal and facial nerves, and
brought about by the persistent stimulation of the former nerve.
Any other explanation of this unusual sign would be welcome. Ormskirk County Hospital,
Ormskirk, Lancs.
WARREN DURRANT.
ESSENTIAL FATTY ACIDS, LIPID METABOLISM, AND ATHEROSCLEROSIS
SIR,-Our interest was aroused by the article by Dr. Kinsell and his colleagues (Feb. 15). Though we are not convinced of the cholesteroldepressing action of essential fatty acids in relation to our own observations confirm some of the of Dr. Kinsell and his colleagues. There is propositions 1 of the direct conversion of linoleic to evidence some acid: we therefore used soybean oil, one of arachidonic the richest sources of linoleic acid. Meanwhile it appears2 that the favourable cholesterol-depressing effect is limited to linoleic and arachidonic acids.
atherosclerosis,
patients (8 men and 2 women) with hypercholesterolaemia investigated. In 8, signs of coronary sclerosis were found (myocardial infarction, angina pectoris). 2 had hypercholes10
were
terolxmia without any clinical symptoms of vascular lesions. In 3 patients the disease was complicated by diabetes, in 1 by hypertension. The average age of the patients was 55-5
patients with hypercholesterol2emia who were admitted hospital but did not receive the soya oil served as controls. In another patient the soya oil was replaced by olive oil. The serum-cholesterol in the control patients reached a 4
to
somewhat lower level than the initial values. In the group the soya oil (fig. 1) an obvious fall in the serumcholesterol level was noted, which persisted throughout treatment. There was no substantial difference between groups a and b. 2 patients were followed after the dietotherapy had been stopped and a rise of the serum-cholesterol was noted, though in one patient (d) the caloric value and fat content of the diet remained unchanged and in the second patient (c) the caloric value of the diet was even reduced from 2700 to 1800 calories, and the fat content from 95 to 65 g., but the soya oil was replaced by animal fats.
receiving
years.
The first week after admission was a control period and the received a diet similar to the one they were accustomed to. Blood samples were taken twice during this period. 6 patients (group a) then received a diet providing 30 calories per kg. of ideal body-weight, fat yielding 30% of the calories, protein 18%, carbohydrate the remainder. All free fat was supplied as soya oil. The vitamin-C intake was about 100 mg. 4 patients (group b) received a diet isocaloric with a day. that of the control period, but all free fat was supplied in the form of soya oil. The average oil intake was 41-5 g. a day. 9 patients had this treatment for five weeks, and 1 for eleven weeks; and 1, as an outpatient, for ten weeks.
patients
1. 2.
Fig. 2-Serum-cholesterol changes in outpatient (broken line) and hospital patient (continuous line).
Mead, J. F., Howton, D. R. J. biol. Chem. 1957, 229, 575. Hegsted, D. M., Cotsis, A., Stare, F. J. J. Nutr. 1957, 63, 377.
All our patients receiving the soybean oil felt better, though the blood-coagulation and the lipoprotein pattern remained unchanged. A shift of the lipoprotein fractions from beta to delta was insignificant. We think that the analogous results obtained in an outpatient exclude the possible effect of bed rest and other non-dietary factors on the cholesterol level (fig. 2). Institute of Human Nutrition, J. VAVŘÍKOVÁ. Prague, Czechoslovakia. PREMEDICATION FOR OUTPATIENT ELECTROCONVULSION THERAPY
SIR,-Electroconvulsion therapy (E.C.T.) for specific mental illnesses is being increasingly used with success in outpatient departments, not only in order to save patients admission to hospital but also to allow them to continue their work whilst receiving such treatment. Further, if given in a general hospital it is acceptable to people who, although in urgent need of it, could not accept what they regard as the " stigma " of attending or entering a mental hospital. In spite of these advantages, however, there remains the very real problem of the apprehension and anxiety which precedes E.c.T. even when modified with thiopentone and suxamethonium chloride, as is our practice. It was to deal with this problem that a small clinical trial was carried out; and, although no control group has yet been studied, the results achieved were of great practical value. Fig. I-Serum-cholesterol
levels before (1), during (II), and after (III) the period of soybean oil diet. Broken line: Findings in patient taking olive oil. a, b, c, d: see text.
30 patients, all attending for outpatient E.C.T. at a general hospital and all complaining of such pretreatment anxiety
1338
apprehension (all having had one or more modified E.C.T.S) were given a small supply of methylpentynol carbamate (’Oblivon C ’), with instructions that on the morning of treatment, two ’Ovets’ (200 mg.) should be taken on rising and two more about an hour before attending hospital-i.e., about and
1.30 P.M. There was a these patients. "
striking improvement in the attitude of most of Grading of their reactions was rated as " much improved ", no change or worse ". 20 "
"
improved ", patients claimed to be " much improved ", 8 more were improved ", only 2 patients felt no different, and none felt worse. I am aware of the failings of such a trial, both from the smallness of its numbers and the absence of These will take time to rectify, although it is
a
J. F. COLLARD.
your note of
the tenth annual commemoration session of the World Health Organisation, you report that Dr. Brock Chisholm, lately directorgeneral of W.H.O., said that the Organisation had come to be widely recognised for efficiency. This was, he thought, due to the unique character of the Executive Board, whose eighteen members act purely as health experts and not as representatives of governments: "Any attempt to convert the Executive Board into a political body would threaten the future of the Organisation ". Some considerable experience in the conduct of small voluntary associations leads me to believe that those responsible for such associations are likely to achieve efficiency similar to that of W.H.O., on its more important level, whenever they adopt the expedient of accepting guidance from advisors not primarily concerned with
June
7
on
authority. Braziers
Park, Ipsden, Oxon.
BRYAN MCFARLAND.
control group. to do so.
WORLD HEALTH ASSEMBLY
SIR,-In
patient. PROTHROMBIN ESTIMATION BY THE TWO-STAGE METHOD
hoped
The importance of these apparently excellent results lies not only in the relief of the pretreatment fears but also in the fact that patients urgently requiring such treatment now feel able to accept it, whereas previously their very real fear and terror prevented them from doing so. Hence this letter. Hellingly Hospital, Hailsham, Sussex.
A continuous thread of a material different in texture and colour from that used for the skin suture is passed under each skin suture. The thread therefore runs parallel with the incisior and lies quite loosely in between each two sutures (fig. 1). Removal is facilitated (fig. 2), the effect of the oedema round the sutures is completely offset, and, even in a poor light, sutures may be removed quickly and painlessly even in a very young or very nervous
J. NORMAN GLAISTER.
A USEFUL ACCESSORY SUTURE
SIR,-I think it might interest people to know about a little procedure or " dodge " I have used for many years to facilitate the removal of sutures. It is particularly useful in children, and has come through many years’ trial very satisfactorily.
-
SIR,-Dr. Wright and his colleagues (May 31, p. 1157) report evidence of slow coagulation when heparinised blood circulates through an extracorporeal bypass. Fibrinogen concentration, antihaemophilic activity, and the platelet-count all fell to about half their normal values. However, the prothrombin, estimated by the two-stage area method of Biggs and Douglas,l showed a striking initial increase. It may not be sufficiently realised that results obtained by this method are directly comparable only if the fibrinogen concentration and the activity of progressive antithrombin are each identical in the plasma samples tested. Where they differ, corrections must be applied to the results (as areaunits observed) before the comparisons are made.
Flbnnogen conce1ltration.-It is well known that when blood clots, thrombin is removed by fibrin. Hardisty and Pinnigeradded varying quantities of purified fibrinogen to the plasma of an afibrinogenxmic girl, and found that about half the thrombin liberated was bound by the normal range of fibrinogen concentration and would thus remain undetected in tests on normal plasma. Their data show the thrombin area observed to be linearly related to the square-root of the fibrinogen concentration (w v); the observed area fell by 22 thrombin mins. per root mg. 0(, increase in the fibrinogen some
concentration in the reaction. From the theoretical model discussed below, it may be anticipated that the slope of this regression would vary inversely with antithrombin potency, and it is possible that deficiency or excess of prothrombin might also affect the relationship, and thus further complicate the interpretation of the test. Without further investigation, it does not seem possible to calculate the appropriate corrections. Progressive antithrombin.-Biggs and DouglasI based their area method on the close correspondence between observed two-stage curves and a theoretical model derived from consecutive first-order reactions; they were careful to point out the implication that the area under the curve will not provide a measure of prothrombin " unless the level of antithrombin is normal ". Imagine an effectively first-order system containing a finite quantity of prothrombin (measured in equivalent thrombin units), a, with thromboplastin and antithrombin, supposedly in excess and therefore constant, denoted by P and A respectively. Then the concentration of thrombin, y, at time t is given by:
where K1 = k,P and K2 k2A, k, and k2 being the reaction constants. The area under the curve relating thrombin concentration to time is a,K2, and is thus inversely proportional to A. The relevant measure of antithrombin is not, of course, the total quantity of thrombin which can be destroyed by the plasma in unlimited time,3 but the rate at which thrombin decays. Therefore, to correct for differences between Ac and AT (the antithrombin in the control and test plasmas respectively), multiply the test area by K.r/Kc, the observed rates of decay of thrombin added to test and control citrated plasma respectively, which are estimates of K2 for the two plasmas. The decay is exponential, so that log. thrombin concentration is linearly related to sampling time, and the slope of this line (the fall in log. thrombin units per unit time, say K log. units per min.) is the required measure of antithrombin activity. =
Fig. I-Continuous thread in position.
Fig. 2-Removal of
sutures.
1. Biggs, R., Douglas, A. S. J. clin. Path. 1953, 6, 15. 2. Hardisty, R. M., Pinniger, J. L. Brit. J. Hœmat. 1956, 2, 139. 3. Astrup, T., Darling, S. Acta physiol. scand. 1942, 4, 293. 4. Quick, A. J. The Physiology and Pathology of Hæmostasis; pp. London, 1951.
164 165.
reflex arc, involving the trigeminal and facial nerves, and
brought about by the persistent stimulation of the former nerve.
Any other explanation of this unusual sign would be welcome. Ormskirk County Hospital,
Ormskirk, Lancs.
WARREN DURRANT.
ESSENTIAL FATTY ACIDS, LIPID METABOLISM, AND ATHEROSCLEROSIS
SIR,-Our interest was aroused by the article by Dr. Kinsell and his colleagues (Feb. 15). Though we are not convinced of the cholesteroldepressing action of essential fatty acids in relation to our own observations confirm some of the of Dr. Kinsell and his colleagues. There is propositions 1 of the direct conversion of linoleic to evidence some acid: we therefore used soybean oil, one of arachidonic the richest sources of linoleic acid. Meanwhile it appears2 that the favourable cholesterol-depressing effect is limited to linoleic and arachidonic acids.
atherosclerosis,
patients (8 men and 2 women) with hypercholesterolaemia investigated. In 8, signs of coronary sclerosis were found (myocardial infarction, angina pectoris). 2 had hypercholes10
were
terolxmia without any clinical symptoms of vascular lesions. In 3 patients the disease was complicated by diabetes, in 1 by hypertension. The average age of the patients was 55-5
patients with hypercholesterol2emia who were admitted hospital but did not receive the soya oil served as controls. In another patient the soya oil was replaced by olive oil. The serum-cholesterol in the control patients reached a 4
to
somewhat lower level than the initial values. In the group the soya oil (fig. 1) an obvious fall in the serumcholesterol level was noted, which persisted throughout treatment. There was no substantial difference between groups a and b. 2 patients were followed after the dietotherapy had been stopped and a rise of the serum-cholesterol was noted, though in one patient (d) the caloric value and fat content of the diet remained unchanged and in the second patient (c) the caloric value of the diet was even reduced from 2700 to 1800 calories, and the fat content from 95 to 65 g., but the soya oil was replaced by animal fats.
receiving
years.
The first week after admission was a control period and the received a diet similar to the one they were accustomed to. Blood samples were taken twice during this period. 6 patients (group a) then received a diet providing 30 calories per kg. of ideal body-weight, fat yielding 30% of the calories, protein 18%, carbohydrate the remainder. All free fat was supplied as soya oil. The vitamin-C intake was about 100 mg. 4 patients (group b) received a diet isocaloric with a day. that of the control period, but all free fat was supplied in the form of soya oil. The average oil intake was 41-5 g. a day. 9 patients had this treatment for five weeks, and 1 for eleven weeks; and 1, as an outpatient, for ten weeks.
patients
1. 2.
Fig. 2-Serum-cholesterol changes in outpatient (broken line) and hospital patient (continuous line).
Mead, J. F., Howton, D. R. J. biol. Chem. 1957, 229, 575. Hegsted, D. M., Cotsis, A., Stare, F. J. J. Nutr. 1957, 63, 377.
All our patients receiving the soybean oil felt better, though the blood-coagulation and the lipoprotein pattern remained unchanged. A shift of the lipoprotein fractions from beta to delta was insignificant. We think that the analogous results obtained in an outpatient exclude the possible effect of bed rest and other non-dietary factors on the cholesterol level (fig. 2). Institute of Human Nutrition, J. VAVŘÍKOVÁ. Prague, Czechoslovakia. PREMEDICATION FOR OUTPATIENT ELECTROCONVULSION THERAPY
SIR,-Electroconvulsion therapy (E.C.T.) for specific mental illnesses is being increasingly used with success in outpatient departments, not only in order to save patients admission to hospital but also to allow them to continue their work whilst receiving such treatment. Further, if given in a general hospital it is acceptable to people who, although in urgent need of it, could not accept what they regard as the " stigma " of attending or entering a mental hospital. In spite of these advantages, however, there remains the very real problem of the apprehension and anxiety which precedes E.c.T. even when modified with thiopentone and suxamethonium chloride, as is our practice. It was to deal with this problem that a small clinical trial was carried out; and, although no control group has yet been studied, the results achieved were of great practical value. Fig. I-Serum-cholesterol
levels before (1), during (II), and after (III) the period of soybean oil diet. Broken line: Findings in patient taking olive oil. a, b, c, d: see text.
30 patients, all attending for outpatient E.C.T. at a general hospital and all complaining of such pretreatment anxiety
1338
apprehension (all having had one or more modified E.C.T.S) were given a small supply of methylpentynol carbamate (’Oblivon C ’), with instructions that on the morning of treatment, two ’Ovets’ (200 mg.) should be taken on rising and two more about an hour before attending hospital-i.e., about and
1.30 P.M. There was a these patients. "
striking improvement in the attitude of most of Grading of their reactions was rated as " much improved ", no change or worse ". 20 "
"
improved ", patients claimed to be " much improved ", 8 more were improved ", only 2 patients felt no different, and none felt worse. I am aware of the failings of such a trial, both from the smallness of its numbers and the absence of These will take time to rectify, although it is
a
J. F. COLLARD.
your note of
the tenth annual commemoration session of the World Health Organisation, you report that Dr. Brock Chisholm, lately directorgeneral of W.H.O., said that the Organisation had come to be widely recognised for efficiency. This was, he thought, due to the unique character of the Executive Board, whose eighteen members act purely as health experts and not as representatives of governments: "Any attempt to convert the Executive Board into a political body would threaten the future of the Organisation ". Some considerable experience in the conduct of small voluntary associations leads me to believe that those responsible for such associations are likely to achieve efficiency similar to that of W.H.O., on its more important level, whenever they adopt the expedient of accepting guidance from advisors not primarily concerned with
June
7
on
authority. Braziers
Park, Ipsden, Oxon.
BRYAN MCFARLAND.
control group. to do so.
WORLD HEALTH ASSEMBLY
SIR,-In
patient. PROTHROMBIN ESTIMATION BY THE TWO-STAGE METHOD
hoped
The importance of these apparently excellent results lies not only in the relief of the pretreatment fears but also in the fact that patients urgently requiring such treatment now feel able to accept it, whereas previously their very real fear and terror prevented them from doing so. Hence this letter. Hellingly Hospital, Hailsham, Sussex.
A continuous thread of a material different in texture and colour from that used for the skin suture is passed under each skin suture. The thread therefore runs parallel with the incisior and lies quite loosely in between each two sutures (fig. 1). Removal is facilitated (fig. 2), the effect of the oedema round the sutures is completely offset, and, even in a poor light, sutures may be removed quickly and painlessly even in a very young or very nervous
J. NORMAN GLAISTER.
A USEFUL ACCESSORY SUTURE
SIR,-I think it might interest people to know about a little procedure or " dodge " I have used for many years to facilitate the removal of sutures. It is particularly useful in children, and has come through many years’ trial very satisfactorily.
-
SIR,-Dr. Wright and his colleagues (May 31, p. 1157) report evidence of slow coagulation when heparinised blood circulates through an extracorporeal bypass. Fibrinogen concentration, antihaemophilic activity, and the platelet-count all fell to about half their normal values. However, the prothrombin, estimated by the two-stage area method of Biggs and Douglas,l showed a striking initial increase. It may not be sufficiently realised that results obtained by this method are directly comparable only if the fibrinogen concentration and the activity of progressive antithrombin are each identical in the plasma samples tested. Where they differ, corrections must be applied to the results (as areaunits observed) before the comparisons are made.
Flbnnogen conce1ltration.-It is well known that when blood clots, thrombin is removed by fibrin. Hardisty and Pinnigeradded varying quantities of purified fibrinogen to the plasma of an afibrinogenxmic girl, and found that about half the thrombin liberated was bound by the normal range of fibrinogen concentration and would thus remain undetected in tests on normal plasma. Their data show the thrombin area observed to be linearly related to the square-root of the fibrinogen concentration (w v); the observed area fell by 22 thrombin mins. per root mg. 0(, increase in the fibrinogen some
concentration in the reaction. From the theoretical model discussed below, it may be anticipated that the slope of this regression would vary inversely with antithrombin potency, and it is possible that deficiency or excess of prothrombin might also affect the relationship, and thus further complicate the interpretation of the test. Without further investigation, it does not seem possible to calculate the appropriate corrections. Progressive antithrombin.-Biggs and DouglasI based their area method on the close correspondence between observed two-stage curves and a theoretical model derived from consecutive first-order reactions; they were careful to point out the implication that the area under the curve will not provide a measure of prothrombin " unless the level of antithrombin is normal ". Imagine an effectively first-order system containing a finite quantity of prothrombin (measured in equivalent thrombin units), a, with thromboplastin and antithrombin, supposedly in excess and therefore constant, denoted by P and A respectively. Then the concentration of thrombin, y, at time t is given by:
where K1 = k,P and K2 k2A, k, and k2 being the reaction constants. The area under the curve relating thrombin concentration to time is a,K2, and is thus inversely proportional to A. The relevant measure of antithrombin is not, of course, the total quantity of thrombin which can be destroyed by the plasma in unlimited time,3 but the rate at which thrombin decays. Therefore, to correct for differences between Ac and AT (the antithrombin in the control and test plasmas respectively), multiply the test area by K.r/Kc, the observed rates of decay of thrombin added to test and control citrated plasma respectively, which are estimates of K2 for the two plasmas. The decay is exponential, so that log. thrombin concentration is linearly related to sampling time, and the slope of this line (the fall in log. thrombin units per unit time, say K log. units per min.) is the required measure of antithrombin activity. =
Fig. I-Continuous thread in position.
Fig. 2-Removal of
sutures.
1. Biggs, R., Douglas, A. S. J. clin. Path. 1953, 6, 15. 2. Hardisty, R. M., Pinniger, J. L. Brit. J. Hœmat. 1956, 2, 139. 3. Astrup, T., Darling, S. Acta physiol. scand. 1942, 4, 293. 4. Quick, A. J. The Physiology and Pathology of Hæmostasis; pp. London, 1951.
164 165.