ultraviolet contact lenses that absorb ultraviolet
light so as to protect their retinas from damage. R J BUCKLEY
Moorfields Eye Hospital, London ECIV 2PD 1 Lovsund P, Nilsson SEG, Lindh H, Oberg PA. Temperature changes in contact lenses in connection with radiation from welding arcs. Scandj Work Envtron Health 1979;5:271-9. 2 Leadbetter C. Welders are told to take off contact lenses. Financial Times 1989 May 22. 3 Health and Safety Executive. Time to focus on some hocus pocus. News release E62:89. London: Health and Safety Executive, 1989. 4 Minerva. Views. BrMedJ 1990;300:620. (3 March.)
Fibromuscular dysplasia of renal arteries and acute loin pain SIR,-In response to the comments of Dr M J Duddy and colleagues on our paper2 we wish to re-emphasise that delay in diagnosis of an acute -tenovascular emergency may be disastrous. Prolonged discussion of the relative incidence of the causes of loin pain and of a non-functioning kidney is futile, but in any case we would strongly dispute that ureteric obstruction is the commonest cause. We do not know how often renovascular emergencies occur, but non-functioning or contracted kidneys are seen often enough in intravenous urograms of patients without symptoms to suggest a fair measure of unrecognised acute disease. We regret the implication that we do not take a history or examine our patients before imposing tests on them. We strongly disagree that intravenous urography has been displaced by ultrasonography and plain abdominal x ray films in patients with loin pain. There is no certainty that an -opacity is a calculus, and pyuria and bacteriuria can coexist with stone disease. Furthermore, as we emphasised, obstruction is not excluded by an undilated pelvicaliceal system on ultrasonography. Intravenous urography is also necessary to confirm normal contralateral function. We still maintain that very poor or absent function shown on urography with an undilated pelvicaliceal system on ultrasonography should lead to angiography. Case 1 shows the catastrophic effects of delay while other tests were being done. We did not discuss further investigation of the non-functioning hydronephrotic kidney because it was not relevant. In any case we would disagree that antegrade pyelography should necessarily be done. The level of obstruction may be clinically obvious, and, particularly in the presence of overwhelming malignancy, it may 'be entirely inappropriate to relieve obstruction by percutaneous nephrostomy. Finally, we agree that where there is a small, poorly functioning kidney another cause for the patient's symptoms should be sought; no further investigations of the kidney are indicated. M C BISHOP
A R MANHIRE
S J STINCHCOMBE Departments of Radiology and Urology, City and University Hospitals, Nottingham NG5 IPB
R H J GREGSON
I Duddy MJ, Bradley SA, Chapman S. Fibromuscular dysplasia of renal arteries and acute loin pain. Br Med J 1990;300:469.
V 17 February.) 2 Stinchcombe SJ, Manhire AR, Bishop MC, Gregson RHJ. Fibromuscular dysplasia of renal arteries: a neglected cause of acutc loin pain. Br MedJ7 1990;300:183-5. (20 January.)
Bovine spongiform encephalopathy SIR,-Professor W B Matthews gave an interesting account of the controversy that exists over the relation between bovine spongiform encephalopathy and scrapie in cattle and sheep, and kuru and
I
(l.MI 300
24 MARCII 1990
Creutzfeldt-Jakob disease in humans.' We were, however, concerned at his point that all suspected cases of Creutzfeldt-Jakob disease "must be seen by a neurologist who is familiar with the disease," and we wonder how often this is practical. In a recent review of the disease Knight listed various symptoms and their frequency of occurrence, with dementia as an invariable feature of all forms, often as an initial symptom.2 The variable presentations include sleep disturbance, weight loss, and non-specific headaches, possibly suggesting a depressive picture; indeed these features may exist in isolation for a fairly prolonged period. In addition, a floridly psychotic picture may appear, with visual and auditory hallucinations accompanied by a rapidly developing dementia.3 The variety of these symptoms in presentation, accompanied by the commonly held view of dementias, often results in patients being referred to a psychiatrist rather than to a neurologist before neurological symptoms develop. It is well recognised that electroencephalography in Creutzfeldt-Jakob disease is a helpful investigation whereas few others are: there is a characteristic pattern of generalised biphasic or triphasic complexes.2 For this reason, we have found it useful to obtain a baseline electroencephalogram for all new patients presenting with a dementing illness, repeating the investigation if there is any substantial change in their mental or neurological state. Should there be reason to suggest Creutzfeldt-Jakob disease, the opinion of a neurologist can then be sought, although, with an annual incidence estimated at 0 49/million in England and Wales (population about 50 million) -about 25 expected new cases annually-few practitioners can have access to a neurologist who is "familiar with the disease." Although Creutzfeldt-Jakob disease is a rare disease of uncertain aetiology, an index of suspicion should exist amongst all practitioners who deal with cases of dementia. We would recommend electroencephalography as a baseline investigation and would question whether the estimates of incidence can be considered valid for a disease that can present in so many different specialties. Given that this figure may not be accurate, what price epidemiological studies of the relation between bovine spongiform encephalopathy and Creutzfeldt-Jakob disease? CHRISTOPHER FEAR MANIKKARASA DEVAKUMAR Ysbyty Gwynedd, Bangor, Gwyniedd LL5 1 2PW I Matthews WB. Bovine spongiform encephalopathy. Br Med J
1990;300:912-3. (17 February.) 2 Knight R. Creutzfeldt-Jakob disease. Br7 Hosp Med 1989;41: 165-7 1. 3 Bethan P. Creutzfeldt-Jakob disease. BrMedJ 1982;284: 1658-9.
Judicial review of the NHS SIR,-After much discussion among ourselves and consultation with our legal advisers we have decided not to appeal against the High Court judgment of Lord Justice Woolf and Mr Justice Pill. In their judgment the 1977 NHS Act offers the secretary of state virtually unrestricted spending powers, extending even to structures and measures as yet without a basis in law. Their conclusions rested heavily on the interpretation of a sentence and the significance of a comma. Our initial inclination was strongly to appeal against this judgment. However, even had the appeal succeeded it would almost certainly have been further challenged in the House of Lords. Much money would have been spent, much time passed before a final verdict late this year or early next-an increasingly academic exercise, with the real issues of authoritarian manipulation not coming through in court. It can give the minister little satisfaction to know
that he has scored a technical victory over the great body of consultants who offer us moral and financial support. Let him make no mistake; this was not the action of some group offended by an attack on professional privilege. It was the voice of the great majority of doctors, nurses, those in the professions ancillary to medicine, and the public itself, protesting in the only potentially effective way we could see against a bill that we feel threatens and demeans the true purposes of medicine. That has not changed. It was a protest too against the methods and morality of the boardroom that are replacing the processes of democratic consent. Ministers should be servants of the public, not its masters. They should be the custodians of the NHS, not its owners. It is not too late for the secretary of state and those to whom he answers to redress the wrongs they seem so firmly determined to impose on profession and public, to accept reasoned amendments, and to respond to sincere concerns by modifying the terms of the bill. The conviction that the government is right and that we must be brought to see how wrong we are has more the flavour of the eastern European "democracies" now passing into history than of Britain with its record of hard fought freedoms. We have decided not to appeal, but let that not be thought to mean that we accept what is being done or the manner of its doing. The profession and the public resent their exclusion from contributing their ideas to the shape of our future medical services. This unity of purpose and concern will be carried forward in the NHS Support Federation, a new alliance of the public and the professions, which is determined to preserve and promote the great purposes of the NHS, whatever the government of the day. H KEEN
NHS Support Group for Judicial Review, Guy's Hospital, London SE l 9RT
How to pay your way through medical school SIR,-In response to Mr A P Armstrong's article I would like to say that, in London at least, drug trials contribute vastly more to student incomes than' charity. By qualification, it is possible for a student to have taken fi blockers and H2 antagonists, antipsychotics, and antidepressants; to have undergone nasogastric intubation, intravenous cannulation, and placement of an indwelling catheter; and to have had a liver biopsy and repeated bone marrow aspirations -and all against a background of weekly semen donation. Female students are barred from many of these trials, but if they have premenstrual tension or menorrhagia they can take vitamin B-6, evening primrose oil, mefenamic acid, or progesterone. In the event of student loans many students will turn to drug trials as a source of tax free income. No trial, no matter how suspect, will be refusable. Students with moderate asthma will not seek treatment from their general practitioners as such treatment would bar them from (i blocker or atopy trials. Female students will all have to claim premenstrual tension of psychotic proportions and gross menorrhagia. A situation can be envisaged in which dangerous trials can recruit subjects, student illnesses go untreated, and trial subjects do not have the conditions relevant to the trial. Economic coercion of this sort would serve not the student, not the drug company, and not the public but would benefit only the Treasury. JAMES BARRETT London N19 5SE 1 Armstrong AP. How to do it: pay your way through medical school. BrM11edJ 1990;300:453-4. (17 February.)
817
light so as to protect their retinas from damage. R J BUCKLEY
Moorfields Eye Hospital, London ECIV 2PD 1 Lovsund P, Nilsson SEG, Lindh H, Oberg PA. Temperature changes in contact lenses in connection with radiation from welding arcs. Scandj Work Envtron Health 1979;5:271-9. 2 Leadbetter C. Welders are told to take off contact lenses. Financial Times 1989 May 22. 3 Health and Safety Executive. Time to focus on some hocus pocus. News release E62:89. London: Health and Safety Executive, 1989. 4 Minerva. Views. BrMedJ 1990;300:620. (3 March.)
Fibromuscular dysplasia of renal arteries and acute loin pain SIR,-In response to the comments of Dr M J Duddy and colleagues on our paper2 we wish to re-emphasise that delay in diagnosis of an acute -tenovascular emergency may be disastrous. Prolonged discussion of the relative incidence of the causes of loin pain and of a non-functioning kidney is futile, but in any case we would strongly dispute that ureteric obstruction is the commonest cause. We do not know how often renovascular emergencies occur, but non-functioning or contracted kidneys are seen often enough in intravenous urograms of patients without symptoms to suggest a fair measure of unrecognised acute disease. We regret the implication that we do not take a history or examine our patients before imposing tests on them. We strongly disagree that intravenous urography has been displaced by ultrasonography and plain abdominal x ray films in patients with loin pain. There is no certainty that an -opacity is a calculus, and pyuria and bacteriuria can coexist with stone disease. Furthermore, as we emphasised, obstruction is not excluded by an undilated pelvicaliceal system on ultrasonography. Intravenous urography is also necessary to confirm normal contralateral function. We still maintain that very poor or absent function shown on urography with an undilated pelvicaliceal system on ultrasonography should lead to angiography. Case 1 shows the catastrophic effects of delay while other tests were being done. We did not discuss further investigation of the non-functioning hydronephrotic kidney because it was not relevant. In any case we would disagree that antegrade pyelography should necessarily be done. The level of obstruction may be clinically obvious, and, particularly in the presence of overwhelming malignancy, it may 'be entirely inappropriate to relieve obstruction by percutaneous nephrostomy. Finally, we agree that where there is a small, poorly functioning kidney another cause for the patient's symptoms should be sought; no further investigations of the kidney are indicated. M C BISHOP
A R MANHIRE
S J STINCHCOMBE Departments of Radiology and Urology, City and University Hospitals, Nottingham NG5 IPB
R H J GREGSON
I Duddy MJ, Bradley SA, Chapman S. Fibromuscular dysplasia of renal arteries and acute loin pain. Br Med J 1990;300:469.
V 17 February.) 2 Stinchcombe SJ, Manhire AR, Bishop MC, Gregson RHJ. Fibromuscular dysplasia of renal arteries: a neglected cause of acutc loin pain. Br MedJ7 1990;300:183-5. (20 January.)
Bovine spongiform encephalopathy SIR,-Professor W B Matthews gave an interesting account of the controversy that exists over the relation between bovine spongiform encephalopathy and scrapie in cattle and sheep, and kuru and
I
(l.MI 300
24 MARCII 1990
Creutzfeldt-Jakob disease in humans.' We were, however, concerned at his point that all suspected cases of Creutzfeldt-Jakob disease "must be seen by a neurologist who is familiar with the disease," and we wonder how often this is practical. In a recent review of the disease Knight listed various symptoms and their frequency of occurrence, with dementia as an invariable feature of all forms, often as an initial symptom.2 The variable presentations include sleep disturbance, weight loss, and non-specific headaches, possibly suggesting a depressive picture; indeed these features may exist in isolation for a fairly prolonged period. In addition, a floridly psychotic picture may appear, with visual and auditory hallucinations accompanied by a rapidly developing dementia.3 The variety of these symptoms in presentation, accompanied by the commonly held view of dementias, often results in patients being referred to a psychiatrist rather than to a neurologist before neurological symptoms develop. It is well recognised that electroencephalography in Creutzfeldt-Jakob disease is a helpful investigation whereas few others are: there is a characteristic pattern of generalised biphasic or triphasic complexes.2 For this reason, we have found it useful to obtain a baseline electroencephalogram for all new patients presenting with a dementing illness, repeating the investigation if there is any substantial change in their mental or neurological state. Should there be reason to suggest Creutzfeldt-Jakob disease, the opinion of a neurologist can then be sought, although, with an annual incidence estimated at 0 49/million in England and Wales (population about 50 million) -about 25 expected new cases annually-few practitioners can have access to a neurologist who is "familiar with the disease." Although Creutzfeldt-Jakob disease is a rare disease of uncertain aetiology, an index of suspicion should exist amongst all practitioners who deal with cases of dementia. We would recommend electroencephalography as a baseline investigation and would question whether the estimates of incidence can be considered valid for a disease that can present in so many different specialties. Given that this figure may not be accurate, what price epidemiological studies of the relation between bovine spongiform encephalopathy and Creutzfeldt-Jakob disease? CHRISTOPHER FEAR MANIKKARASA DEVAKUMAR Ysbyty Gwynedd, Bangor, Gwyniedd LL5 1 2PW I Matthews WB. Bovine spongiform encephalopathy. Br Med J
1990;300:912-3. (17 February.) 2 Knight R. Creutzfeldt-Jakob disease. Br7 Hosp Med 1989;41: 165-7 1. 3 Bethan P. Creutzfeldt-Jakob disease. BrMedJ 1982;284: 1658-9.
Judicial review of the NHS SIR,-After much discussion among ourselves and consultation with our legal advisers we have decided not to appeal against the High Court judgment of Lord Justice Woolf and Mr Justice Pill. In their judgment the 1977 NHS Act offers the secretary of state virtually unrestricted spending powers, extending even to structures and measures as yet without a basis in law. Their conclusions rested heavily on the interpretation of a sentence and the significance of a comma. Our initial inclination was strongly to appeal against this judgment. However, even had the appeal succeeded it would almost certainly have been further challenged in the House of Lords. Much money would have been spent, much time passed before a final verdict late this year or early next-an increasingly academic exercise, with the real issues of authoritarian manipulation not coming through in court. It can give the minister little satisfaction to know
that he has scored a technical victory over the great body of consultants who offer us moral and financial support. Let him make no mistake; this was not the action of some group offended by an attack on professional privilege. It was the voice of the great majority of doctors, nurses, those in the professions ancillary to medicine, and the public itself, protesting in the only potentially effective way we could see against a bill that we feel threatens and demeans the true purposes of medicine. That has not changed. It was a protest too against the methods and morality of the boardroom that are replacing the processes of democratic consent. Ministers should be servants of the public, not its masters. They should be the custodians of the NHS, not its owners. It is not too late for the secretary of state and those to whom he answers to redress the wrongs they seem so firmly determined to impose on profession and public, to accept reasoned amendments, and to respond to sincere concerns by modifying the terms of the bill. The conviction that the government is right and that we must be brought to see how wrong we are has more the flavour of the eastern European "democracies" now passing into history than of Britain with its record of hard fought freedoms. We have decided not to appeal, but let that not be thought to mean that we accept what is being done or the manner of its doing. The profession and the public resent their exclusion from contributing their ideas to the shape of our future medical services. This unity of purpose and concern will be carried forward in the NHS Support Federation, a new alliance of the public and the professions, which is determined to preserve and promote the great purposes of the NHS, whatever the government of the day. H KEEN
NHS Support Group for Judicial Review, Guy's Hospital, London SE l 9RT
How to pay your way through medical school SIR,-In response to Mr A P Armstrong's article I would like to say that, in London at least, drug trials contribute vastly more to student incomes than' charity. By qualification, it is possible for a student to have taken fi blockers and H2 antagonists, antipsychotics, and antidepressants; to have undergone nasogastric intubation, intravenous cannulation, and placement of an indwelling catheter; and to have had a liver biopsy and repeated bone marrow aspirations -and all against a background of weekly semen donation. Female students are barred from many of these trials, but if they have premenstrual tension or menorrhagia they can take vitamin B-6, evening primrose oil, mefenamic acid, or progesterone. In the event of student loans many students will turn to drug trials as a source of tax free income. No trial, no matter how suspect, will be refusable. Students with moderate asthma will not seek treatment from their general practitioners as such treatment would bar them from (i blocker or atopy trials. Female students will all have to claim premenstrual tension of psychotic proportions and gross menorrhagia. A situation can be envisaged in which dangerous trials can recruit subjects, student illnesses go untreated, and trial subjects do not have the conditions relevant to the trial. Economic coercion of this sort would serve not the student, not the drug company, and not the public but would benefit only the Treasury. JAMES BARRETT London N19 5SE 1 Armstrong AP. How to do it: pay your way through medical school. BrM11edJ 1990;300:453-4. (17 February.)
817
