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TYRAMINE PRESSOR RESPONSE IN DEPRESSION
511 These results will need confirmation under " blind " conditions. Such a trial is currently being planned. In addition to the therapies administered above, a third group will receive L-tryptophan and nicotinamide together with dothiepin, a tricyclic antidepressant which has been shown under blind conditions to be superior to amitriptyline.s The possibility that depressives may have abnormally high levels of tryptophan pyrrolase and that nicotinamide on its own might consequently act as an antidepressant agent is also being explored. The prophylactic use of a lower dose of the above combination in recurrent depression, as compared with lithium, is also being considered. I am grateful to the patients and their consultants and to Cambrian Chemicals Ltd. who supplied L-tryptophan (’Opti-
max’) without supplements. Academic Department of Psychiatry, Middlesex Hospital Medical School, London W1P 8AA; and West Park Hospital, Epsom,
Surrey.
IDAVID A. MACSWEENEY.
TYRAMINE PRESSOR RESPONSE IN DEPRESSION p. 234) was correct in suptyramine pressor response in depression (June 14, p. 1317) was not carried out by a physician blind " as to whether the subject was a depressive patient
SIR,—DR Abrams (Aug. 2,
posing
that the
per week when patients are on dialysis (it is remarkable that all patients reported complete loss of libido and potency on the day of dialysis). In our study, if libido prior to the disease was rated 100%, patients rated libido at the time of the interview as 64 ± 34%, only 5/18 rated present libido at less than 50% of their libido prior to their
disease. In general, the patients’ ratings agreed well with those given by their wives (mean difference 196; range - 20 to +50%). Retrospectively, 13/18 of the patients reported complete loss of libido in terminal urxmia prior to the beginning of haemodialysis; only 1/18 patients noticed no change. At that time, erection was unimpaired in no more than 2/17 patients and was much reduced (4/17) or completely lost (12/17) in the remainder. Under maintenance hæmodialysis, however, erection was reported to be normal in 13/18 patients, impaired in 3/18, and completely abolished in 2/18. After the beginning of dialysis, considerable time was required before the present state of sexual activity was reached (13-9 ±7-4 months), presumably reflecting the time required for adaptation to the procedure and for loss of
anxiety.
The relatively low incidence of failure of physical performance supports Levy’s previous conclusion8 that emotional rather than physical facts are mainly responsible for sexual dysfunction in dialysed patients.
J. BOMMER
"
control. We agree that bias can influence any test, but we do not think it was operating in this investigation. The tyramine pressor response in these subjects was carried out as part of an assessment of the adrenergic effects of various antidepressive drugs, and we had no particular expectation one way or another of the baseline results (on which our report was based) of depressive and control subjects. The possibility of bias cannot be entirely eliminated, but it is difficult to see how the test could be carried out blindly, as it must be performed by a clinician who could not fail to detect whether the subject was suffering from a depressive illness
Dialysestation, Medizinische Universitätsklinik, Heidelberg, Germany.
or a
or not.
Department of Clinical
Pharmacology, St. Bartholomew’s Hospital, London EC1A 7BE.
KARABI GHOSE PAUL TURNER.
Medical Research Council
Neuropsychiatry Laboratory, West Park Hospital, Epsom, Surrey.
ALEC COPPEN.
are impressed by the close agreement of tht sexual performance of male dialysis patients founc by Levy and Wynbrandt7 with those found in our study. We interviewed 18 married men on home-dialysis (agl 48.1 ± 8.5years; duration of dialysis 31-1 ±11-7 months hsmatocrit 29.1 ± 5.1%; normotension in 15/18 withou antihypertensive drugs). Simultaneously, their wives were interviewed separately. The frequency of intercourse prio to their disease was reported to be 3-4/week by the patient and 2-8/week by their wives; under maintenance hsemo dialysis, frequency was reported to be 1’8/week by th patients and 1-3/week by their wives. While the figures of Levy and Wynbrandt are thus com pletely confirmed by our study, we do not think tha the frequency of intercourse gives a fair and complet estimate of the patients’ sexual performance. It must b remembered that the available time is reduced bv 3 dav
7.
SIR,—With regard to the paper by Dr Saxena and others (Aug. 30, p. 403) several points are not clear, probably because of the way the material has been condensed. It is stated that " 97 children ... had intravenous pyelography and micturating cystourethrography after their first proved infection ", but I can find figures relating to only 58 children having had both examinations (table III). Over 41 % of 58 is not the 41 % of 97 implied in the summary. Furthermore, 4 children had no i.v.p. and 32 no M.C.U.—does this mean that some had no radiology, or did a number have M.C.U. without i.v.p.? If so, why ? The results could be stated in " round percentages "
SIR,-We
6.
URINARY-TRACT INFECTION IN CHILDREN
as
LIFE ON HÆMODIALYSIS data
E. RITZ W. TSCHÖPE K. ANDRASSY.
on
Lipsedge, M. S., Rees, W. L., Pike, D. J. Psychopharmacologia, 1971, 19, 153. Levy, N. B., Wynbrandt, G. D. Lancet, 1975, i, 1328.
follows:
85% girls had a normal i.v.p. 66% boys had a normal i.v.p. 66% girls had a normal M.c.u. 61% boys had a normal M.c.u. 63%girls had a normal i.v.p. and M.c.u. 43% boys had a normal i.v.p. and M.c.u.
Following a study of the last two paragraphs of " Results ", perhaps the best yield of abnormal results would be obtained by concentrating on the investigation of boys aged under 3 years; otherwise it would seem that normal results are to be expected in about 2 cases in every 3 investigated. Excluding this group, is M.C.U. justified following one infection, when in some hands infectionrates of 20% are reported following this examination ? Why did 32 children not have a M.C.U.—were these in the group of 73 with a normal LV.P., did they have trivial symptoms, did they have an unusually high rate of recurrent infection ? Am I correct in thinking that 20 children and no more were found to have reflux and that 4 children (3 girls) were found to have renal scars, 1 of the latter girls not having reflux ? Finally, having discovered the vesicoureteric reflux or 8.
Levy, N. B. (editor) Living
or
Dying; p. 127. Springfield, Ill.,
1974.
max’) without supplements. Academic Department of Psychiatry, Middlesex Hospital Medical School, London W1P 8AA; and West Park Hospital, Epsom,
Surrey.
IDAVID A. MACSWEENEY.
TYRAMINE PRESSOR RESPONSE IN DEPRESSION p. 234) was correct in suptyramine pressor response in depression (June 14, p. 1317) was not carried out by a physician blind " as to whether the subject was a depressive patient
SIR,—DR Abrams (Aug. 2,
posing
that the
per week when patients are on dialysis (it is remarkable that all patients reported complete loss of libido and potency on the day of dialysis). In our study, if libido prior to the disease was rated 100%, patients rated libido at the time of the interview as 64 ± 34%, only 5/18 rated present libido at less than 50% of their libido prior to their
disease. In general, the patients’ ratings agreed well with those given by their wives (mean difference 196; range - 20 to +50%). Retrospectively, 13/18 of the patients reported complete loss of libido in terminal urxmia prior to the beginning of haemodialysis; only 1/18 patients noticed no change. At that time, erection was unimpaired in no more than 2/17 patients and was much reduced (4/17) or completely lost (12/17) in the remainder. Under maintenance hæmodialysis, however, erection was reported to be normal in 13/18 patients, impaired in 3/18, and completely abolished in 2/18. After the beginning of dialysis, considerable time was required before the present state of sexual activity was reached (13-9 ±7-4 months), presumably reflecting the time required for adaptation to the procedure and for loss of
anxiety.
The relatively low incidence of failure of physical performance supports Levy’s previous conclusion8 that emotional rather than physical facts are mainly responsible for sexual dysfunction in dialysed patients.
J. BOMMER
"
control. We agree that bias can influence any test, but we do not think it was operating in this investigation. The tyramine pressor response in these subjects was carried out as part of an assessment of the adrenergic effects of various antidepressive drugs, and we had no particular expectation one way or another of the baseline results (on which our report was based) of depressive and control subjects. The possibility of bias cannot be entirely eliminated, but it is difficult to see how the test could be carried out blindly, as it must be performed by a clinician who could not fail to detect whether the subject was suffering from a depressive illness
Dialysestation, Medizinische Universitätsklinik, Heidelberg, Germany.
or a
or not.
Department of Clinical
Pharmacology, St. Bartholomew’s Hospital, London EC1A 7BE.
KARABI GHOSE PAUL TURNER.
Medical Research Council
Neuropsychiatry Laboratory, West Park Hospital, Epsom, Surrey.
ALEC COPPEN.
are impressed by the close agreement of tht sexual performance of male dialysis patients founc by Levy and Wynbrandt7 with those found in our study. We interviewed 18 married men on home-dialysis (agl 48.1 ± 8.5years; duration of dialysis 31-1 ±11-7 months hsmatocrit 29.1 ± 5.1%; normotension in 15/18 withou antihypertensive drugs). Simultaneously, their wives were interviewed separately. The frequency of intercourse prio to their disease was reported to be 3-4/week by the patient and 2-8/week by their wives; under maintenance hsemo dialysis, frequency was reported to be 1’8/week by th patients and 1-3/week by their wives. While the figures of Levy and Wynbrandt are thus com pletely confirmed by our study, we do not think tha the frequency of intercourse gives a fair and complet estimate of the patients’ sexual performance. It must b remembered that the available time is reduced bv 3 dav
7.
SIR,—With regard to the paper by Dr Saxena and others (Aug. 30, p. 403) several points are not clear, probably because of the way the material has been condensed. It is stated that " 97 children ... had intravenous pyelography and micturating cystourethrography after their first proved infection ", but I can find figures relating to only 58 children having had both examinations (table III). Over 41 % of 58 is not the 41 % of 97 implied in the summary. Furthermore, 4 children had no i.v.p. and 32 no M.C.U.—does this mean that some had no radiology, or did a number have M.C.U. without i.v.p.? If so, why ? The results could be stated in " round percentages "
SIR,-We
6.
URINARY-TRACT INFECTION IN CHILDREN
as
LIFE ON HÆMODIALYSIS data
E. RITZ W. TSCHÖPE K. ANDRASSY.
on
Lipsedge, M. S., Rees, W. L., Pike, D. J. Psychopharmacologia, 1971, 19, 153. Levy, N. B., Wynbrandt, G. D. Lancet, 1975, i, 1328.
follows:
85% girls had a normal i.v.p. 66% boys had a normal i.v.p. 66% girls had a normal M.c.u. 61% boys had a normal M.c.u. 63%girls had a normal i.v.p. and M.c.u. 43% boys had a normal i.v.p. and M.c.u.
Following a study of the last two paragraphs of " Results ", perhaps the best yield of abnormal results would be obtained by concentrating on the investigation of boys aged under 3 years; otherwise it would seem that normal results are to be expected in about 2 cases in every 3 investigated. Excluding this group, is M.C.U. justified following one infection, when in some hands infectionrates of 20% are reported following this examination ? Why did 32 children not have a M.C.U.—were these in the group of 73 with a normal LV.P., did they have trivial symptoms, did they have an unusually high rate of recurrent infection ? Am I correct in thinking that 20 children and no more were found to have reflux and that 4 children (3 girls) were found to have renal scars, 1 of the latter girls not having reflux ? Finally, having discovered the vesicoureteric reflux or 8.
Levy, N. B. (editor) Living
or
Dying; p. 127. Springfield, Ill.,
1974.