Glasgow: city of managerial culture SIR,-Dr Tony Delamothe's article generally reflects faithfully the problems and indeed the progress that have occurred since Mr Peterken was appointed as general manager.' In one case, however, Dr Delamothe seems to have acquired a distorted view of the facts, which in fairness to Mr Peterken needs to be corrected. The general manager did not decide to transfer maternity services from the deprived east end of the city "west" to Stobhill. Instead he had to decide where to build one new maternity hospital to replace two existing facilities, each with their own catchment population, presently sited at Stobhill and near the Royal Infirmary, which is also the home of the university department of obstetrics and gynaecology. The Royal Infirmary lies almost on the southern edge of the combined catchment area whereas Stobhill lies further north (not west), just to the south of the geographical centre of the district. The childbearing population around Stobhill is in fact larger than that around the Royal Infirmary. The catchment area of Stobhill has its own areas of deprivation, and the distance that carless inhabitants of these areas would have to travel to reach maternity services in the Royal Infirmary is further than the distance that those from the deprived areas around the Royal Infirmary would have to travel to Stobhill. The decision to build at Stobhill was therefore sensible in terms of both patient care and finance. Unfortunately, when the decision was announced the university department and the Royal Infirmary mounted a vociferous campaign that caused the decision to be reversed, thus losing these benefits. Far from a medical outcry correcting managerial decisions, one view is that a sensible decision has been subverted by pressure from special interest groups-a perennial Glasgow problem hinted at in your quotation from Mr Peterken but not discussed in your article. Glasgow badly needs a strategic plan for the care of its local population untrammelled by the influence of special interest groups, be they medical, academic, managerial, or traditional. Mr Peterken should be given credit for attempting such a plan, although his method and conclusions were sometimes sadly flawed. E H McLAREN Stobhill General Hospital, Glasgow G21 3UW I Delamothe T. Glasgow: city of managerial culture. 301:654-6. (29 September.)

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Potassium and magnesium in essential hypertension SIR,-Dr P S Patki and colleagues report that potassium treatment lowered systolic and diastolic blood pressure and total cholesterol concentration. They also state that 26 of the 37 patients were taking thiazide diuretics before entry into the study. Potassium supplementation of patients concurrently taking thiazides has been shown to prevent insulin resistance.2 In addition, only 60% of patients who develop glucose intolerance when taking thiazides revert to normal six months after stopping treatment.3 In view of the suggested link between hypertension and hypercholesterolaemia and insulin resistance4 potassium supplementation in this study may have reversed a prolonged state of insulin resistance secondary to previous thiazide treatment and thus led to the reduction in plasma cholesterol concentrations. This possibility should have been resolved by

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analysing the effect of order of treatment. If the decrease in cholesterol concentration was greater in those subjects receiving placebo early in the study this would argue strongly, for a waning effect of the thiazides on insulin resistance. In the absence of this information the role of potassium in modifying plasma cholesterol concentrations remains unresolved. CHRIS O'CALLAGHAN LAURENCE HOWES Austin Hospital, Heidelberg, Victoria 3084, Australia 1 Patki PS, Singh J, Gokhale SV, Shrotri DS, Patwardhan B. Efficacy of potassium and magnesium in essential hypertension: a double blind, placebo controlled, crossover study. BMJ 1990;301:521-3. (15 September.) 2 Helderman JH, Elahi D, Anderson DK, et al. Prevention of the glucose intolerance of thiazides by maintenance of body potassium. Diabetes 1983;32:106-11. 3 Medical Research Council Working Party on Mild to Moderate Hypertension. Adverse reactions to bendrofluazide and propanolol for the treatment of mild hypertension. Lancet 1981 ;ii: 539-43. 4 Reaven GM. Role of insulin resistance in human disease. Diabetes 1988;37: 1595-607.

Trauma of the lower urinary tract SIR,-We are concerned by Mr Anthony Deane's recommendations for the treatment of bladder and urethral injuries associated with pelvic disruption.' These injuries carry a high mortality and the survival of patients often depends on the natural pelvic tamponade. Early laparotomy without addressing this problem in these critically injured patients will result in release of this pressure, increased haemorrhage, diffuse intravascular coagulation, and, all too commonly, death. Suprapubic catheter tracts quickly become contaminated. Thus, further orthopaedic management to the bony pelvis to restore the natural anatomy using internal fixation is associated with a high infection risk. Chronic osteitis after internal fixation is extremely difficult to eradicate. Failure to reduce and stabilise a disrupted pelvic fracture, however, leads to considerable long term disability. Though suprapubic catheterisation may be the safest way for the urological management of urethral tears, it is often less than ideal for the patient as a whole. We suggest that more emphasis should be placed on the combined orthopaedic and urological approach to these injuries. Early direct repair of the urethra should perhaps be combined with stabilisation of the skeleton, in keeping with recent trends in managing multiply injured patients. M D BIRCHER W M MURPHY M BAILEY

Epsom District Hospital, Epsom KT18 7EG I Deane A. Trauma of the lower urinary tract. BMJ 1990;301: 545-7. (15 September.)

Diagnosing cancer of the pancreas SIR,-Mr Jeremy N Thompson's editorial gave a succinct update on the strengths and weaknesses of the various diagnostic modalities currently available for diagnosing pancreatic cancer.' We believe, however, that radioimmunoscintigraphy should be added to his list. We recently conducted a controlled study of radioimmunoscintigraphy in 30 patients (15 with pancreatic cancer and 15 related controls). Each patient was scanned four days after an intravenous injection of 2 mg (80 MBq) of a cocktail of CA19-9

and carcinoembryonic antigen monoclonal antibodies labelled with iodine-131. Planar and single photon emission computed tomography scans were assessed blind by two experienced observers, who graded scans as positive, equivocal, or negative for pancreatic cancer. Blood was also collected for the measurement of serum concentrations of carcinoembryonic antigen and CA19-9. Planar imaging was totally unreliable and insensitive, but single photon emission computed tomography correctly identified 12 of 15 cancer patients with one false negative result and 11 of 15 controls with three false positive results (sensitivity 80%; specificity 73%). Serum concentrations of carcinoembryonic antigen and CA19-9 were available for 16 patients, and the values were normal in three patients with cancer and inappropriately raised in three controls. These six patients were correctly classified by radioimmunoscintigraphy. This is the first thorough study evaluating the ability of radioimmunoscintigraphy to diagnose pancreatic cancer. Unlike other studies of smaller groups of patients23 we included a control group of patients. Our results show that by using the latest nuclear medical techniques (single photon emission computed tomography and adaptive filtering) radioimmunoscintigraphy can correctly diagnose most patients presenting with pancreatic cancer and has a low false positive rate. In this study radioimmunoscintigraphy was clearly better than assays of serum antigen concentrations. Antibody imaging of tumours is still not reliable enough to recommend more widespread use, but our results show great promise for this technique. ALEX R ATTARD DAVID N TAYLOR IAN A FRASER

Walsgrave Hospital, Coventry CV2 2DX I Thompson JN. Diagnosing cancer of the pancreas. BMJ 1990;

301:775-6. (6 October.) 2 Ballantyne KC, Perkins AC, Selby C, Wastie ML, Hardcastle JD. Imaging of pancreatic and colorectal cancer using antibody fragments: a preliminary evaluation. EurJSurgOncol 1988;14: 393-8. 3 Montz R, Klapdor R, Rothe B, Heller M. Immunoscintigraphy and radioimmunotherapy in patients with pancreatic carcinoma. Nuclear Medicine 1986;25:239-44.

Delayed detection of congenital hearing loss SIR,-Dr N J Wild and colleagues pointed out the importance of early audiometric investigation of children at high risk of congenital hearing impairment.' Certain paramyxoviruses-for example, mumps and measles viruses-and the togavirus that causes rubella have been recognised to have an affinity for the cochleovestibular system of the inner ear.' Maternal rubella in the first trimester of pregnancy often results in the fetus having lesions of sensory and other structures of the inner ear. In addition to the early sensorineural disease another lesion may develop, manifesting itself in people aged over 20 as conductive deafness caused by otosclerosis. Immunocytochemical evidence of three viral antigens, mumps, measles, and rubella has been found in all footplates of the stapes from 42 patients who had undergone stapedectomies at various stages of otosclerosis.' Healthy footplates showed no expression of viral antigens. Nucleocapsids resembling the measles virus have been noted in otosclerotic bone examined under the transmission electron microscope.4 The viral antigens are most strongly expressed by the cells of the perivascular tissue and by the inflammatory cells and osteoclasts present in the resorption lacunae of the otosclerotic process. This suggests that the aggressive proliferation of the vascular connective tissue might be initiated in the

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early stages of otospongiosis, and subsequently maintained, by the viruses. A prospective study of children notified to the national congenital rubella syndrome surveillance programme to determine how many develop otosclerosis in later life might be worth while. I FRIEDMANN

Stanmore, Middlesex HA7 3NR W ARNOLD

Kanpom Hospital, 6000 Lucerne 16, Switzerland 1 Wild NJ, Sheppard S, Smithells RW, Holzel H, Jones 'G. Delayed detection of congenital hearing loss in high risk infants. BMJ 1990;301:903-5. (20 October.) 2 Friedmann I. The pathology of the ear. Oxford: Blackwell, 1974. 3 Arnold W, Friedmann I. Otosclerosis-an inflammatory disease of the otic capsule of viral aetiology. J Larvngol Otol 1988;102:865-71. 4 McKenna MJ, Mills GB, Galey FR, Linthicum FH. Filamentous structures morphologically similar to viral nucleocapsids in otosclerotic lesions in two patients. Am J Otolaryngol 1986;71:25-8.

and the fact that the cumulative incidence of AIDS in patients with haemophilia A has been reported to be more than five times higher than in those with haemophilia B,h which may be related to the fact that factor VIII is more highly contaminated with factor XIII than is factor IX (the treatment product used in haemophilia B). Until there is increased availability and use of recombinant factor VIII preparations or solvent and detergent treated factor VIII concentrates derived from monoclonal antibodies (which appear to be devoid of immunosuppressive properties (E Berntrop et al and A Tagliaferri et al, nineteenth international conference of the World Federation of Haemophilia, Washington, DC, 1990) or until other forms of replacement therapy are developed -for example, gene transfer-identifying possible cofactors for infection with HIV, such as factor VIII induced immunosuppression, and successful intervention would certainly seem to be not only just and equitable for haemophiliac patients, but also of prophylactic importance. RICHARD J ABLIN

Treatment of viral pharyngitis or flu SIR,-Dr LindaBeeley suggests that a combination of aspirin and paracetamol might be useful in the treatment of viral pharyngitis or influenza.' It was most unfortunate that her response to the questioner made, no reference to the fact that aspirin is specifically contraindicated for this purpose in children because of the risk of developing Reye's syndrome.23 Indeed, some evidence suggests that Reye's syndrome in adults may also be associated with aspirin used to treat influenza.4 SUSAN M HALL

Port Jefferson, New York 11777, United States I Dyer C. Justice versus equity for haemophiliacs with AIDS. BMJ7 1990;301:776. (6 October.) 2 Ablin RJ, Bartkus JM, Gonder MJ. Blood product immunosuppression and the acquired immunodeficiency syndrome. Ann Intern Med 1986;104:130. 3 Ablin RJ, Whyard TC, Polgar J, Muszbek L. Delineation and characterization of plasma factor XIII as contributory to immunomodulation by factor VIII concentrates [Abstract]. Thromb Haemostas 1989;62:331. 4 Freedman J, Mazaheri R, Read S, Garvey MB, Teitel J. Humoral and cellular immune abnormalities in adult hemophiliacs followed over a 2-year period. Diagn Clin Immunol 1987;5: 30-40. 5 AIDS Update. Hemophilia exchange, Medical Bulletin No 117. New York: The National Hemophilia Foundation, 1990. 6 Centers for Disease Control. Update: acquired immunodeficiency syndrome (AIDS) in persons with hemophilia. MMWR 1984;33:589-91.

Communicable Disease Surveillance Centre, London NW9 SEQ 1 Beeley L. Any Questions. BMJ7 1990;301:544. (15 September.) 2 Anonymous. Reye's syndrome and aspirin. BMJ7 1986;292:1590. 3 Hall SM, Plaster PA, Glasgow JFT, Hancock P. Preadmission antipyretics in Reye's syndrome. Arch Dis Child 1988;63: 857-66. 4 Meythaler JM, Varma RR. Reyes syndrome in adults: diagnostic considerations. Arch Intern Med 1987;147:61-4.

Justice versus equity for haemophiliacs with AIDS SIR,-MS Clare Dyer's editorial only partially exemplifies the dilemma of haemophiliacs.' Certainly, corrective measures for screening out high risk donors and heat treatment of blood products to reduce infection with HIV have been introduced. Patients with haemophilia A, however, are still faced with the lifetime regimen of infusion of 50 000-60 000 units annually of factor VIII concentrate, which, when viewed with knowledge of the immunosuppressive properties of factor VIII,2' 3 calls for the same responsible attention to be given to HIV contaminated blood products until such suppression is shown to be unimportant. The importance of immunosuppression induced by factor VIII to predisposition to HIV infection in haemophiliacs is possibly exemplified by the high incidence of AIDS-like immune aberrations in patients who do not have antibodies to HIV,4 suggesting that such aberrations are attributable to factors other than HIV; the variation in the geographical incidence in AIDS associated haemophilia in the United States'-for example, haemophiliacs in New York City, an area with one of the highest number of haemophiliac patients with AIDS, were principal recipients of factor VIII concentrate that was not heat treated and which contained the greatest amount of factor XIII contaminant and immunosuppressive activity';

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A painful process SIR,-The recent anonymous personal view is dismaying. ' The anguish suffered by the author at being accused of wrongly diagnosing and managing a case and the cost incurred by the health authority would have been unnecessary if routine necropsy had been the practice. Necropsy numbers are dwindling, sadly, and this important form of medical audit is being ignored. A NICOL

Leighton Hospital, Crewe CWl'I 4QJ 1 Anonymous. A painful process. BMJ 1990;301:1052-3. (3 November.)

Management of intercostal drains SIR,-We are sorry to disappoint Minerva, who recently seemed squeamish about intercostal tubes.' The study from Copenhagen published in Thorax2 to which Minerva refers described a simple method of treating iatrogenic pneumothoraces when there is no continuing air leak. This is an alternative to repeated chest aspiration. The small teflon catheter employed would be inadequate for treating the commoner spontaneous and traumatic pneumothoraces for two reasons. Firstly, in the presence of a continuing air leak intercostal drains should be connected to suction apparatus (for example, a Vernon Thompson pump) with an underwater seal to ensure complete lung inflation.' Secondly, small catheters frequently become blocked with blood clot or fibrin debris.4 Many patients referred to our thoracic surgical unit

with unresolving pneumothoraces have been mismanaged with tiny chest drains that are often in the wrong position. In most cases thoracotomy is avoided by a period of correct management with a tube of adequate bore (in our experience at least 28 Charriere gauge). Minerva is wrong to imply that all pneumothoraces can be properly treated with the 2 mm plastic cannula and flutter valve. It may be suitable for the small group of patients described in the Copenhagen study but would result in ineffective treatment of most patients with this life threatening condition. D R HARRISS T R GRAHAM

Nottingham City Hospital, Nottingham NG5 lPB I Anonymous. Views. BM3r 1990;301:940. (20 October.) 2 Laub M, Miilman N, Muller D, Struve-Christensen E. Role of small calibre chest tube drainage for iatrogenic pneumothorax. 7'horax 1990;45:748-9. 3 Holden MP. Management of intercostal drainage tubes. In: Practice of cardiothoracic surgery. Bristol: John Wright and Sons, 1982:3-6. 4 Treasure T, Murphy JP. Pneumothorax. Surgerv 1989;75: 1780-6.

Nobel prizes given for clinical research SIR,-Mr Rex Rhein writes that "Transplantation of other organs, such as hearts, lungs, and livers, all depend on the work Dr Murray began when he transplanted the first human kidney from one identical twin to the cotwin in December 1954."' The great contribution that Dr Murray has made to the practice of organ transplantation has to be acknowledged, but I have always believed that the work that was really crucial to organ transplantation was that of Mr Roy Calne, who showed the effects of mercaptopurine in canine renal transplantation, working at the Buckstown Browne Farm of the Royal College of Surgeons of England. The work was first applied clinically in the renal unit of the Royal Free Hospital in 1960 in patients under my care. Indeed, theBMJ published an account of these cases and commented on them in an editorial.2 ' These cases caused a good deal of interest at the time, and Professor Hamburger came over from Paris to discuss the work and gave much encouragement. The discussions reassured Calne that his concept was well founded and encouraged him to proceed in the search for better immunosuppressive drugs. He was given the opportunity of doing this in Boston, and azathioprine was found to be better than mercaptopurine. Clinical organ transplantation grew in the next decades almost more rapidly than we had thought possible. There will always be much interest in its early days, and I write to record again these events, which I think were of the first importance in its development. JOHN HOPEWELL Royal Free Hospital, London NW3 2QG 1 Rhein R. Nobel prizes for clinical research. BMJ 1990;301:894.

(20 October.) 2 Hopewell J, Calne RY, Beswick 1. Three clinical cases of renal transplantation. BMJ 1964;i:411-2. 3 Anonymous. Mlore transplanted kidneys [Editorial]. BMJ 1964;i:386-7.

Correction A new new general practice An editorial error occurred in this letter by Dr Michael Bourke (27 October, p 986). The third sentence of the second paragraph should read "Certainly we practised from our homes, and our wives were an integral part of the service" and not our lives as published. 1165