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SHALL WE DISCARD B.C.G.?
312 IRON LOSSES IN DIALYSIS PATIENTS SiR,ňWe were interested in the paper by Dr. Hocken and Dr. Marwah.l We should like, however, to correct their interpretation of some of our previous work.2 Our study demonstrated a marked increase in iron losses in patients at the beginning of regular dialysis treatment when compared with the period immediately preceding dialysis. We stated that the weekly blood-sampling of up to 40 ml. could not explain the large increase in iron losses detected; we certainly did not say that sampling losses were unWe have subsequently published work3 important. indicating how the blood loss at each dialysis has been reduced by changes in technique and in the type of coil used. In the case of coil dialysis, blood left in the coil constitutes the major source of blood loss. The methods used to demonstrate this involved both the use of wholebody monitoring and of other radioisotopic techniques. At the same time we demonstrated the considerable inaccuracies of the simple colorimetric methods of determining residual blood losses in the artificial kidney such as have been used by Hocken and Marwah. While we agree that blood-sampling in these patients should be reduced to a minimum, these losses represent only a fraction of the total weekly blood losses. The statement that " patients with chronic renal failure do not absorb iron by mouth " also requires qualification. It would be more accurate to state that oral-iron absorption is diminished in chronic renal failure 4,5; however, to imply from this observation that parenteral-iron therapy is indicated in chronic renal failure irrespective of the patients’ iron status is unjustified. It has first to be shown that regularly dialysed patients can effectively utilise the administered iron. Edwards et a1. demonstrated that administration of parenteral iron to these patients leads to an increase in the number of stainable iron granules in the erythroblast. They did not, however, record an improvement in the patients haemoglobin concentration following this therapy. Although others have noted a rise in hxmoglobin concentration after parenteral-iron therapy given to patients with iron deficiency developing during regular dialysis,7 we have failed to confirm this. 8 In part this has been due to the fact that frank iron deficiency (peripheral hypochromia, low serum-iron concentration, and a raised transferrin saturation) is extremely rare in our experience. We would suggest, therefore, that further work is indicated before all patients on regular dialysis are placed
parenteral-iron therapy.
on
Western Infirmary, Glasgow. Scottish Research Reactor Centre, East Kilbride, Glasgow. Western
Infirmary, Glasgow. Gateside Hospital, Greenock.
D. H. LAWSON. K. BODDY. A. L. LINTON. G. WILL.
SHALL WE DISCARD B.C.G.? is
SIR,-Contact tracing by means of the tuberculin test proving difficult in many schools because so many child-
have had B.C.G. in the past. The mass-miniatureunits are not keen to X-ray the under 14s, and this throws a greater burden on the chest clinics. I ren
radiography
that B.C.G. came out well in the M.R.C. trials. Will some medical officers of health and principal school medical officers be bold enough--or rash enough-to say goodbye to s.c.G. ? Perhaps we could make a start by leaving B.c.G. till the last year at school for all children (including children of Asian stock and the T.B. contacts). I await a counter-attack by the protagonists of B.c.G.
appreciate
London Borough of Redbridge Health and Welfare Department, Ilford, Essex.
ETHANOL ADMINISTRATION IN PREMATURE LABOUR SIR,-Ethanol is now widely used to prevent premature labour.I-4 Ethanol crosses the placental barrier freely, and equilibrium is rapidly established. If an infant is born shortly after ethanol administration to the mother, it will have about the same blood-alcohol concentration as the mother. Newborn infants, particularly if they are premature, metabolise ethanol at about half the rate of adults,Ó but this fact is unrelated to the effect on the central nervous system. On the basis of a premature twin delivery, where one twin died, Seppala et al. have suggested that caution is needed in the use of ethanol in cases of premature labour with a viable fetus. Their own case does not justify any incrimination of ethanol treatment, however. The twin that died weighed only 1100 g. while the other twin, born 15 minutes later, weighed 1940 g. With such a difference in weight, twin A was obviously already severely jeopardised, and its chance of survival was small indeed. The recorded blood-ethanol values do not provide any basis for the inference that ethanol was the cause of death or even contributed to it. Wagner et al.1i have clearly demonstrated that premature infants do very well on ethanol concentrations similar to those measured in the twins, and our own material, comprising more than 200 cases,7 does not support the contention of the Finnish workers. Prematurity is associated with 75% of the perinatal mortality, and any attempt at prevention of prematurity is therefore of such importance that it should not be discredited on the basis of
suspicion. Department of Obstetrics and Gynecology, Cornell University Medical College, New York, N.Y. 10021, U.S.A.
39, 115.
Edwards,
Seppälä,
SIR,-We are honoured that Dr. Fuchs has noted our communication. The purpose of our report was to emphasise our earlier biochemical findings on the development of liver alcohol dehydrogenase and to correlate them to the in-vivo elimination of ethanol in the newborn infant. The implications of the delayed elimination of ethanol in the low-birth-weight infant must be related to the pharmacological effects on diverse cellular functions, including those on the central nervous system. The C.N.S. effects remain ill-defined and are largely unknown in low-birth-weight infants, especially growth-retarded 2.
3. 4. 5.
M.
S., Pegrum, G. D., Curtis, J. R. Lancet, 1970, ii, 491. 7. Eschbach, J. W, Cook, J. D., Finch, C. A. Clin. Sci. 1970, 38, 191. 8. Lawson, D. H., Boddy, K., King, P. C., Linton, A. L., Will, G. Unpublished. 6.
FRITZ FUCHS.
z* This letter was shown to Dr. Raiha and Dr. whose reply follows.-ED. L.
1. 1. Hocken, A. H., Marwah, P. K. Lancet, 1971, i, 164. 2. Lawson, D. H., Will, G., Boddy, K., Linton, A. L. Proc. Eur. Dialysis Transplant Ass. 1968, 5, 179. 3. Will, G., Lawson, D. H., King, P., Boddy, K., Linton, A. L. Nephron, 1970, 7, 331. 4. Dubach, R., Callender, S. T. E., Moore, C. V. Blood, 1948, 5, 526. 5. Boddy, K., Lawson, D. H., Linton, A. L., Will, G. Clin. Sci. 1970,
J. K. ANAND.
6. 7.
Fuchs, F., Fuchs, A.-R., Poblete, V. F., Jr., Risk, A. Am. J. Obstet. Gynec. 1967, 99, 627. Luukkainen, T., Väistö, L., Järvinen, P. A. Acta obstet. gynec. scand. 1967, 46, 486. Mehra, P., Raghavan, K. S., Devi, P. K., Chaudhury, R. R. Int. J. Gynœc. Obstet. 1970, 82, 160. Patel, N., Macnaughton, M. C. Abstracts of 19th British Congress on Obstetrics and Gynæcology, Dublin, May, 1971. Wagner, L., Wagner, G., Guerrero, J. Am. J. Obstet. Gynec. 1970, 108, 308. Seppälä, M., Räihä, N. C. R., Tamminen, V. Lancet, 1971, i, 1188. Lauersen, N. H., Fuchs, F. Annual Meeting of German Perinatal Society, Berlin, 1970 (in the press).
parenteral-iron therapy.
on
Western Infirmary, Glasgow. Scottish Research Reactor Centre, East Kilbride, Glasgow. Western
Infirmary, Glasgow. Gateside Hospital, Greenock.
D. H. LAWSON. K. BODDY. A. L. LINTON. G. WILL.
SHALL WE DISCARD B.C.G.? is
SIR,-Contact tracing by means of the tuberculin test proving difficult in many schools because so many child-
have had B.C.G. in the past. The mass-miniatureunits are not keen to X-ray the under 14s, and this throws a greater burden on the chest clinics. I ren
radiography
that B.C.G. came out well in the M.R.C. trials. Will some medical officers of health and principal school medical officers be bold enough--or rash enough-to say goodbye to s.c.G. ? Perhaps we could make a start by leaving B.c.G. till the last year at school for all children (including children of Asian stock and the T.B. contacts). I await a counter-attack by the protagonists of B.c.G.
appreciate
London Borough of Redbridge Health and Welfare Department, Ilford, Essex.
ETHANOL ADMINISTRATION IN PREMATURE LABOUR SIR,-Ethanol is now widely used to prevent premature labour.I-4 Ethanol crosses the placental barrier freely, and equilibrium is rapidly established. If an infant is born shortly after ethanol administration to the mother, it will have about the same blood-alcohol concentration as the mother. Newborn infants, particularly if they are premature, metabolise ethanol at about half the rate of adults,Ó but this fact is unrelated to the effect on the central nervous system. On the basis of a premature twin delivery, where one twin died, Seppala et al. have suggested that caution is needed in the use of ethanol in cases of premature labour with a viable fetus. Their own case does not justify any incrimination of ethanol treatment, however. The twin that died weighed only 1100 g. while the other twin, born 15 minutes later, weighed 1940 g. With such a difference in weight, twin A was obviously already severely jeopardised, and its chance of survival was small indeed. The recorded blood-ethanol values do not provide any basis for the inference that ethanol was the cause of death or even contributed to it. Wagner et al.1i have clearly demonstrated that premature infants do very well on ethanol concentrations similar to those measured in the twins, and our own material, comprising more than 200 cases,7 does not support the contention of the Finnish workers. Prematurity is associated with 75% of the perinatal mortality, and any attempt at prevention of prematurity is therefore of such importance that it should not be discredited on the basis of
suspicion. Department of Obstetrics and Gynecology, Cornell University Medical College, New York, N.Y. 10021, U.S.A.
39, 115.
Edwards,
Seppälä,
SIR,-We are honoured that Dr. Fuchs has noted our communication. The purpose of our report was to emphasise our earlier biochemical findings on the development of liver alcohol dehydrogenase and to correlate them to the in-vivo elimination of ethanol in the newborn infant. The implications of the delayed elimination of ethanol in the low-birth-weight infant must be related to the pharmacological effects on diverse cellular functions, including those on the central nervous system. The C.N.S. effects remain ill-defined and are largely unknown in low-birth-weight infants, especially growth-retarded 2.
3. 4. 5.
M.
S., Pegrum, G. D., Curtis, J. R. Lancet, 1970, ii, 491. 7. Eschbach, J. W, Cook, J. D., Finch, C. A. Clin. Sci. 1970, 38, 191. 8. Lawson, D. H., Boddy, K., King, P. C., Linton, A. L., Will, G. Unpublished. 6.
FRITZ FUCHS.
z* This letter was shown to Dr. Raiha and Dr. whose reply follows.-ED. L.
1. 1. Hocken, A. H., Marwah, P. K. Lancet, 1971, i, 164. 2. Lawson, D. H., Will, G., Boddy, K., Linton, A. L. Proc. Eur. Dialysis Transplant Ass. 1968, 5, 179. 3. Will, G., Lawson, D. H., King, P., Boddy, K., Linton, A. L. Nephron, 1970, 7, 331. 4. Dubach, R., Callender, S. T. E., Moore, C. V. Blood, 1948, 5, 526. 5. Boddy, K., Lawson, D. H., Linton, A. L., Will, G. Clin. Sci. 1970,
J. K. ANAND.
6. 7.
Fuchs, F., Fuchs, A.-R., Poblete, V. F., Jr., Risk, A. Am. J. Obstet. Gynec. 1967, 99, 627. Luukkainen, T., Väistö, L., Järvinen, P. A. Acta obstet. gynec. scand. 1967, 46, 486. Mehra, P., Raghavan, K. S., Devi, P. K., Chaudhury, R. R. Int. J. Gynœc. Obstet. 1970, 82, 160. Patel, N., Macnaughton, M. C. Abstracts of 19th British Congress on Obstetrics and Gynæcology, Dublin, May, 1971. Wagner, L., Wagner, G., Guerrero, J. Am. J. Obstet. Gynec. 1970, 108, 308. Seppälä, M., Räihä, N. C. R., Tamminen, V. Lancet, 1971, i, 1188. Lauersen, N. H., Fuchs, F. Annual Meeting of German Perinatal Society, Berlin, 1970 (in the press).