- Email: [email protected]
TREATMENT OF ASCITES
1213 The different populations between 5",, and 14%.3 " frequency of HL-A 27 is clearly higher in classic rheumatoid arthritis than in a random Finnish population,’although
routine administration of NaCl in an approximate balance with sodium losses are safe and effective measures to improve the late results of this treatment.
the difference is not statistically very significant (p < 0025). The diagnosis of rheumatoid arthritis is certain in our patient population. All are Waaler-Rose positive, all have symmetrical polyarthritis with radiological erosions, 16 have subcutaneous rheumatoid nodules, and none has back symptoms typical of ankylosing spondylitis. Rheumatoid arthritis has many facets, from a mild seronegative monoarthritis to a malignant disease. Our patients are a sample " " from the most rheumatoid type of patients. Our series gives no information of whether HL-A 27 is typical only of this type of rheumatoid arthritis. However, the clinical picture in our patients is quite different from that of ankylosing spondylitis or Reiter’s disease, which are known to be associated with this antigen. In our opinion this question is still worth further evaluation.
REMO NACCARATO G. CARLO STURNIOLO Istituto di Patologia Speciale Medic ROBERTO FARINI E di Metodologia Clinica, ANGELA D’ANGELO Policlinico Universitario, ELENA OSSI. 35100 Padova, Italy.
This communication is part of
a
work in progress for the is
Computerised Follow-up Survey of Arthritis, Heinola, and financially supported by the Finnish Academy of Sciences.
Rheumatism Foundation Hospital, 18120 Heinola 12, Finland.
H. ISOMÄKI M. NISSILÄ K. KOOTA J. MARTIO.
Department of Serology and
Bacteriology, University of Helsinki, Finland.
A. TILIKAINEN.
TRAUMATIC ENCEPHALOPATHY IN A YOUNG BOXER
SIR,—I was very interested in the account (Oct. 19, p. 928) of a boxer aged 24 with traumatic encephalopathy. In nearly 40 years of vetting boxers, this is the youngest case to be reported. From the history it appears that he did not have any symptoms or signs while boxing as an amateur, and his parents confirmed that he did not develop symptoms until after he had had 16 professional fights. It is unlikely that he developed the syndrome whilst he was an amateur, since all amateur boxers are examined before boxing in a and have an extensive examination before internationals. Senior amateur boxers box at the most 3 three-minute rounds whilst professionals box up to 15 three-minute rounds, hence they are likely to receive far more blows to the head. Again, if an amateur boxer receives an overt injury or is obviously outclassed, the bout is stopped immediately whilst in professional boxing the referees are contest
circumspect. only encountered one amateur boxer with the syndrome. He was an Army instructor who boxed 8 hours a day, five days a week ! It is not surprising that he cerebellar developed atrophy. Kaplan and Browderin their studies on professional boxers in the United States found that sparring partners had more E.E.G. changes than other boxers. The slugger-
not so
,
TREATMENT OF ASCITES
SIR,-We read with great interest the paper by Professor Sherlock and her colleagues (May 18, p. 949). Their results are to some extent different from ours in 13 patients with decompensated liver cirrhosis (alcoholic 3, post-hepatic 9, cirrhosis with primary liver cancer 1), aged 40-72 years, all of them resistant to diuretic treatment. The ultrafiltration and reinfusion of ascitic fluid was done by the same device (’Rhodhiascit ’) during 20 sessions lasting between 3 and 20 hours. The mean protein concentration of the reinfused ascitic fluid was doubled. In the report by Professor Sherlock and her colleagues, sodium depletion is not recorded as a major problem. At the very beginning of our experience we observed a significant fall in plasma-sodium concentration, sometimes associated with severe drowsiness. Therefore, we tried to correct what we believe to be one of the main complications of this treatment in two ways: (a) By giving, starting from the 6th hour of the sessions, an intravenous hypertonic solution of 3% NaCI in amounts depending on plasma-sodium concentration and sodium losses with urine and ultrafiltrate. (b) By inducing a prompt diuresis early in the sessions with preliminary administration of unconcentrated ascitic fluid (about 1000 ml. in 60 minutes). The sustained diuresis was then maintained by a continuous infusion of concentrated ascitic fluid and, in a few patients, by administering intravenously 20-100 mg. of frusemide. In this way, a significant increase in urine output, leading to shorter sessions and hence to a decrease in ultrafiltrate volume, was secured. Since the urinary sodium concentration was lower than that found in the ultrafiltrate (85-6 and 135-5 mEq. per !., respectively), a significant sodium-sparing effect was obtained.
According to Professor Sherlock and her colleagues, we did a complete aspiration of the ascitic fluid. Howwe believe that a preliminary rapid infusion of a ever, never
limited
amount
of unconcentrated ascitic fluid and the
I have
type of boxer who will accept any number of blows in order to get in a telling blow himself also gets more abnormal E.E.G.S than the average boxer. I agree that amateur boxers should not spar with professionals. The latter are much better trained and can direct their punches more accurately. Young professionals also should not act as sparring partners to more experienced
professionals. In amateur boxers, only those of equal weight and experience spar together, using heavy headgear and gloves up to 12 oz. (normally 8 oz.). The cavum septum pellucidum is not pathognomonic of the punch-drunk syndrome. This also occurs in women who have
never
boxed.
J. L. BLONSTEIN, 130
Harley Street,
London W1N 1AH
President of the Medical Commission of the Amateur International Boxing Association.
ROYAL MEDICAL BENEVOLENT FUND: CHRISTMAS APPEAL I remind your readers who are intending the President’s Appeal that we like to distribute gifts to our beneficiaries in good time for Christmas ? I would ask all individuals, societies, and groups who have not yet done so to send their contributions as soon as possible to the Director, Royal Medical Benevolent Fund, 24 King’s Road, Wimbledon, London SW19 8QN.
to
SIR,—May respond to
GEOFFREY BATEMAN, 7. 8.
Aho, K., Ahvonen, P., Lassus, A., Sievers, K., Tiilikainen, A. ibid. 1973, ii, 157. Brewerton, D. A., Caffrey, M., Hart, F. D., James, D. C. O., Nicholls, A., Sturrock, R. D. ibid. 1973, i, 904.
Honorary Treasurer, Royal Medical Benevolent Fund. 1.
Kaplan, H. A., Browder, J. J. Am. med. Ass. 1954, 156, 1138.
routine administration of NaCl in an approximate balance with sodium losses are safe and effective measures to improve the late results of this treatment.
the difference is not statistically very significant (p < 0025). The diagnosis of rheumatoid arthritis is certain in our patient population. All are Waaler-Rose positive, all have symmetrical polyarthritis with radiological erosions, 16 have subcutaneous rheumatoid nodules, and none has back symptoms typical of ankylosing spondylitis. Rheumatoid arthritis has many facets, from a mild seronegative monoarthritis to a malignant disease. Our patients are a sample " " from the most rheumatoid type of patients. Our series gives no information of whether HL-A 27 is typical only of this type of rheumatoid arthritis. However, the clinical picture in our patients is quite different from that of ankylosing spondylitis or Reiter’s disease, which are known to be associated with this antigen. In our opinion this question is still worth further evaluation.
REMO NACCARATO G. CARLO STURNIOLO Istituto di Patologia Speciale Medic ROBERTO FARINI E di Metodologia Clinica, ANGELA D’ANGELO Policlinico Universitario, ELENA OSSI. 35100 Padova, Italy.
This communication is part of
a
work in progress for the is
Computerised Follow-up Survey of Arthritis, Heinola, and financially supported by the Finnish Academy of Sciences.
Rheumatism Foundation Hospital, 18120 Heinola 12, Finland.
H. ISOMÄKI M. NISSILÄ K. KOOTA J. MARTIO.
Department of Serology and
Bacteriology, University of Helsinki, Finland.
A. TILIKAINEN.
TRAUMATIC ENCEPHALOPATHY IN A YOUNG BOXER
SIR,—I was very interested in the account (Oct. 19, p. 928) of a boxer aged 24 with traumatic encephalopathy. In nearly 40 years of vetting boxers, this is the youngest case to be reported. From the history it appears that he did not have any symptoms or signs while boxing as an amateur, and his parents confirmed that he did not develop symptoms until after he had had 16 professional fights. It is unlikely that he developed the syndrome whilst he was an amateur, since all amateur boxers are examined before boxing in a and have an extensive examination before internationals. Senior amateur boxers box at the most 3 three-minute rounds whilst professionals box up to 15 three-minute rounds, hence they are likely to receive far more blows to the head. Again, if an amateur boxer receives an overt injury or is obviously outclassed, the bout is stopped immediately whilst in professional boxing the referees are contest
circumspect. only encountered one amateur boxer with the syndrome. He was an Army instructor who boxed 8 hours a day, five days a week ! It is not surprising that he cerebellar developed atrophy. Kaplan and Browderin their studies on professional boxers in the United States found that sparring partners had more E.E.G. changes than other boxers. The slugger-
not so
,
TREATMENT OF ASCITES
SIR,-We read with great interest the paper by Professor Sherlock and her colleagues (May 18, p. 949). Their results are to some extent different from ours in 13 patients with decompensated liver cirrhosis (alcoholic 3, post-hepatic 9, cirrhosis with primary liver cancer 1), aged 40-72 years, all of them resistant to diuretic treatment. The ultrafiltration and reinfusion of ascitic fluid was done by the same device (’Rhodhiascit ’) during 20 sessions lasting between 3 and 20 hours. The mean protein concentration of the reinfused ascitic fluid was doubled. In the report by Professor Sherlock and her colleagues, sodium depletion is not recorded as a major problem. At the very beginning of our experience we observed a significant fall in plasma-sodium concentration, sometimes associated with severe drowsiness. Therefore, we tried to correct what we believe to be one of the main complications of this treatment in two ways: (a) By giving, starting from the 6th hour of the sessions, an intravenous hypertonic solution of 3% NaCI in amounts depending on plasma-sodium concentration and sodium losses with urine and ultrafiltrate. (b) By inducing a prompt diuresis early in the sessions with preliminary administration of unconcentrated ascitic fluid (about 1000 ml. in 60 minutes). The sustained diuresis was then maintained by a continuous infusion of concentrated ascitic fluid and, in a few patients, by administering intravenously 20-100 mg. of frusemide. In this way, a significant increase in urine output, leading to shorter sessions and hence to a decrease in ultrafiltrate volume, was secured. Since the urinary sodium concentration was lower than that found in the ultrafiltrate (85-6 and 135-5 mEq. per !., respectively), a significant sodium-sparing effect was obtained.
According to Professor Sherlock and her colleagues, we did a complete aspiration of the ascitic fluid. Howwe believe that a preliminary rapid infusion of a ever, never
limited
amount
of unconcentrated ascitic fluid and the
I have
type of boxer who will accept any number of blows in order to get in a telling blow himself also gets more abnormal E.E.G.S than the average boxer. I agree that amateur boxers should not spar with professionals. The latter are much better trained and can direct their punches more accurately. Young professionals also should not act as sparring partners to more experienced
professionals. In amateur boxers, only those of equal weight and experience spar together, using heavy headgear and gloves up to 12 oz. (normally 8 oz.). The cavum septum pellucidum is not pathognomonic of the punch-drunk syndrome. This also occurs in women who have
never
boxed.
J. L. BLONSTEIN, 130
Harley Street,
London W1N 1AH
President of the Medical Commission of the Amateur International Boxing Association.
ROYAL MEDICAL BENEVOLENT FUND: CHRISTMAS APPEAL I remind your readers who are intending the President’s Appeal that we like to distribute gifts to our beneficiaries in good time for Christmas ? I would ask all individuals, societies, and groups who have not yet done so to send their contributions as soon as possible to the Director, Royal Medical Benevolent Fund, 24 King’s Road, Wimbledon, London SW19 8QN.
to
SIR,—May respond to
GEOFFREY BATEMAN, 7. 8.
Aho, K., Ahvonen, P., Lassus, A., Sievers, K., Tiilikainen, A. ibid. 1973, ii, 157. Brewerton, D. A., Caffrey, M., Hart, F. D., James, D. C. O., Nicholls, A., Sturrock, R. D. ibid. 1973, i, 904.
Honorary Treasurer, Royal Medical Benevolent Fund. 1.
Kaplan, H. A., Browder, J. J. Am. med. Ass. 1954, 156, 1138.