1294
military protection should be provided for relief efforts where necessary. High-risk populations should be placed under UN
protection; direct credit without controls to governments should be reduced; children in industrialised countries should be educated about less developed countries; and, last, an early warning international action board should be set up to plan swift action and
follow-up. Without major change in present direction we will be seeing famines and suffering on an inconcievable scale within the decade. Despite dreadful misery and suffering, the means to effect real change lies within our grasp if we only have the will to use it. International Community for the Relief of Starvation and Suffering, ICROSS Rural Health Programmes, PO 15619, Mbagathi, Kenya
MICHAEL K. MEEGAN
Psychological aspects of loin-pain/ haematuria syndrome SiR,—Your Sept 19 editorial neglects salient psychological and
psychiatric issues in many patients presenting with unexplained loin pain. Dr Lucas and colleagues (Oct 24, p 1038) and others have recorded clinically significant psychopathology associated with severe unremitting loin pain in patients with and without haematuria. In the first report of this syndrome’ two of three patients were "artificially increasing their reading of their oral thermometers to simulate a high fever" and others2 have referred to a pattern of "exaggeration of symptoms". Ifudu et al3 described individuals seeking medical care by the feigning of physical symptoms including renal pain and haematuria. A much more common clinical problem is the psychological exacerbation of physical symptoms, especially pain, in patients with established disease or in whom there is demonstrable pathology that may not adequately explain their symptoms. This is the conundrum presented by patients with so-called loin pain and haematuria syndrome. Rates of psychiatric disturbance reported in uncontrolled series range from 6 of 254 in one, through to all patients in two other reports (one with 3 patients, the other with 9) showing important behavioural and emotional disturbance.s.6 In one report’ patients were receiving psychiatric treatment for pethidine addiction, alcohol misuse, anorexia nervosa, and "hysterical symptoms". These diagnoses do not exclude the possibility of co-existing renal pathology, but these clinical data have tended to be treated merely as a complication of chronic pain rather than a signpost of the psychiatric contribution to symptoms. The report by Chin,7 which you discuss, describes 10 patients with persistent unexplained loin pain and haematuria. Psychiatric evaluation in this group reportedly excluded such a disorder, and Chin suggests such evaluation to "exclude personality disorder ... and drug dependence". He also refers to psychiatrists having provided "counselling and support" to his patients. The psychological contribution to the pain complaint and the role of other psychiatric conditions (eg, somatoform pain disorder, depression) that can arise in the absence of personality disorder are not addressed. This is not a controlled study and does not account for the part such continuing psychiatric care may have played in the successful relief of pain. The fact that health-care personnel have been predominant among patients with loin-pain/haematuria syndrome2,4,7 should raise greater concern that in some cases this syndrome may be related to the somatoform and/or factitious disorders. Such disorders are common in health-care personnel partly because of their exposure to models of symptoms, illness, and procurement of care. You point out several dilemmas in loin-pain/haematuria syndrome: no one knows what causes the pain; there is no reliable confirmatory test; treatment is usually ineffective; and after nephrectomy the pain frequently returns on the other side in the previously normal kidney. Such a set of observations closely fits somatoform disorders and suggests strongly that psychiatric factors may be paramount, especially in view of the frequency of overt psychiatric disturbance.8,9 Our experience of this disorder has been with 7 patients who were assessed in a consultation liaison psychiatry service at a large metropolitan hospital. Diagnoses of somatoform pain disorder,
factitious disorder, major depression, post-traumatic stress disorder, in addition to personality disorder, and, less commonly, drug dependence, were detected. A past history of sexual abuse was present in 3 patients, a factor known to predispose to otherwise unexplained chronic pain syndromes. We have also found that some of these patients may be successfully treated at a multidisciplinary pain clinic and with rehabilitation, although this is difficult to establish if patients are not psychiatrically assessed at the earliest stage. Loin-pain/haematuria syndrome remains an unresolved diagnostic and therapeutic puzzle. Future reports and research need to include a more critical approach to the basis of the symptoms, and to pay attention to psychosocial data and evaluation of treatment from the medical, surgical, and, particularly, psychiatric
perspectives. Department of Psychiatry, University of Queensland, and Princess Alexandra Hospital, Woolloongabba 4102, Australia
BRIAN KELLY
1. Little PJ, Sloper JS, de Wardener HE. A syndrome of loin pain and haematuria associated with disease of peripheral renal arteries. Q J Med 1967; 142: 253-59. 2. Burden RP, Booth LJ, Ockenden BG, et al. Intrarenal changes in adult patients with recurrent haematuria and loin pain. Q J Med 1975; 175: 433-47. 3. Ifudu O, Kolasinski SL, Friedman EA. Brief report: kidney-related Munchausen’s syndrome. N Engl JMed 1992; 327: 388-89. 4. Leaker BR, Godge MP, Patel A, Neild GH. Haemostatic changes in the loin pain and
haematuria syndrome: secondary to renal vasospasm? Q J Med 1990; 281: 969-79. GM, Higgins PM. The natural history of the loin pain/haematuria syndrome. Br J Urol 1982; 54: 613-15. 6. Sheil AGR, Ibels LS, Pollock C, Graham JC, Short J. Treatment of loin pain/haematuria syndrome by renal autotransplantation. Lancet 1987; ii: 907-08. 7. Chin JL. Loin pain-haematuria syndrome: role for renal transplantation. J Urol 1992; 147: 987-89. 8. Dworkin RH, Caligor E. Psychiatric diagnosis and chronic pain: DSMIII-R and beyond.J Pain Symptom Manag 1988; 3: 87-98. 9. Lipowski ZJ. Somatization and depression. Psychosomatics 1990; 31: 13-21. 5. Aber
Surveillance for small-for-gestational-age fetuses SiR,—The importance of avoiding intervention where a healthy fetus just happens to be genetically small is sensible, but Dr Almstrom and colleagues’ (Oct 17, p 936) report does not meet this aim, at least in one respect. There were 426 women in the study, of whom 242 had female and only 184 had male babies-a male/female ratio of 0-76, compared with the usual ratio of 1-05. This is obviously because the selection criterion for the study was that a scan estimated the fetus to weigh less than 2 SD below the mean for gestation at or after 31 completed weeks, and of course female babies are on average smaller than male infants at that stage of pregnancy. Had it been possible to allow for fetal sex (and assuming a population sex ratio of 1 -05) I calculate that 34 women with female fetuses would have avoided unnecessary intensive surveillance (but of course 34 additional women with male fetuses would have been offered surveillance). Presumably this would have improved the effectiveness of the intervention, though it is difficult to be certain of this since there was no non-intervention control group. Aberdeen Maternity Hospital, Aberdeen AB9 2ZA, UK
M.H.HALL
Energy supplementation during pregnancy and postnatal growth SiR,—There are two ways of reading the stimulating report by Professor Kusin and colleagues (Sept 12, p 623) and both leave us somewhat disconcerted. Their findings can indeed be interpreted as documentation for a supposed biological effect of supplementary feeding during pregnancy on postnatal growth. The effect of energy supplementation was, however, estimated from observations on less than 30% of participants (35% of enrolled women complied and for 80% of their infants sufficient data were obtained). By restricting the analysis to those subjects only, Kusin et al lost the methodological advantages of randomisation. Even though compliers and non-compliers "were similar in physiological and socioeconomic characteristics" these characteristics may have introduced confounding. Furthermore, differential self-selection
military protection should be provided for relief efforts where necessary. High-risk populations should be placed under UN
protection; direct credit without controls to governments should be reduced; children in industrialised countries should be educated about less developed countries; and, last, an early warning international action board should be set up to plan swift action and
follow-up. Without major change in present direction we will be seeing famines and suffering on an inconcievable scale within the decade. Despite dreadful misery and suffering, the means to effect real change lies within our grasp if we only have the will to use it. International Community for the Relief of Starvation and Suffering, ICROSS Rural Health Programmes, PO 15619, Mbagathi, Kenya
MICHAEL K. MEEGAN
Psychological aspects of loin-pain/ haematuria syndrome SiR,—Your Sept 19 editorial neglects salient psychological and
psychiatric issues in many patients presenting with unexplained loin pain. Dr Lucas and colleagues (Oct 24, p 1038) and others have recorded clinically significant psychopathology associated with severe unremitting loin pain in patients with and without haematuria. In the first report of this syndrome’ two of three patients were "artificially increasing their reading of their oral thermometers to simulate a high fever" and others2 have referred to a pattern of "exaggeration of symptoms". Ifudu et al3 described individuals seeking medical care by the feigning of physical symptoms including renal pain and haematuria. A much more common clinical problem is the psychological exacerbation of physical symptoms, especially pain, in patients with established disease or in whom there is demonstrable pathology that may not adequately explain their symptoms. This is the conundrum presented by patients with so-called loin pain and haematuria syndrome. Rates of psychiatric disturbance reported in uncontrolled series range from 6 of 254 in one, through to all patients in two other reports (one with 3 patients, the other with 9) showing important behavioural and emotional disturbance.s.6 In one report’ patients were receiving psychiatric treatment for pethidine addiction, alcohol misuse, anorexia nervosa, and "hysterical symptoms". These diagnoses do not exclude the possibility of co-existing renal pathology, but these clinical data have tended to be treated merely as a complication of chronic pain rather than a signpost of the psychiatric contribution to symptoms. The report by Chin,7 which you discuss, describes 10 patients with persistent unexplained loin pain and haematuria. Psychiatric evaluation in this group reportedly excluded such a disorder, and Chin suggests such evaluation to "exclude personality disorder ... and drug dependence". He also refers to psychiatrists having provided "counselling and support" to his patients. The psychological contribution to the pain complaint and the role of other psychiatric conditions (eg, somatoform pain disorder, depression) that can arise in the absence of personality disorder are not addressed. This is not a controlled study and does not account for the part such continuing psychiatric care may have played in the successful relief of pain. The fact that health-care personnel have been predominant among patients with loin-pain/haematuria syndrome2,4,7 should raise greater concern that in some cases this syndrome may be related to the somatoform and/or factitious disorders. Such disorders are common in health-care personnel partly because of their exposure to models of symptoms, illness, and procurement of care. You point out several dilemmas in loin-pain/haematuria syndrome: no one knows what causes the pain; there is no reliable confirmatory test; treatment is usually ineffective; and after nephrectomy the pain frequently returns on the other side in the previously normal kidney. Such a set of observations closely fits somatoform disorders and suggests strongly that psychiatric factors may be paramount, especially in view of the frequency of overt psychiatric disturbance.8,9 Our experience of this disorder has been with 7 patients who were assessed in a consultation liaison psychiatry service at a large metropolitan hospital. Diagnoses of somatoform pain disorder,
factitious disorder, major depression, post-traumatic stress disorder, in addition to personality disorder, and, less commonly, drug dependence, were detected. A past history of sexual abuse was present in 3 patients, a factor known to predispose to otherwise unexplained chronic pain syndromes. We have also found that some of these patients may be successfully treated at a multidisciplinary pain clinic and with rehabilitation, although this is difficult to establish if patients are not psychiatrically assessed at the earliest stage. Loin-pain/haematuria syndrome remains an unresolved diagnostic and therapeutic puzzle. Future reports and research need to include a more critical approach to the basis of the symptoms, and to pay attention to psychosocial data and evaluation of treatment from the medical, surgical, and, particularly, psychiatric
perspectives. Department of Psychiatry, University of Queensland, and Princess Alexandra Hospital, Woolloongabba 4102, Australia
BRIAN KELLY
1. Little PJ, Sloper JS, de Wardener HE. A syndrome of loin pain and haematuria associated with disease of peripheral renal arteries. Q J Med 1967; 142: 253-59. 2. Burden RP, Booth LJ, Ockenden BG, et al. Intrarenal changes in adult patients with recurrent haematuria and loin pain. Q J Med 1975; 175: 433-47. 3. Ifudu O, Kolasinski SL, Friedman EA. Brief report: kidney-related Munchausen’s syndrome. N Engl JMed 1992; 327: 388-89. 4. Leaker BR, Godge MP, Patel A, Neild GH. Haemostatic changes in the loin pain and
haematuria syndrome: secondary to renal vasospasm? Q J Med 1990; 281: 969-79. GM, Higgins PM. The natural history of the loin pain/haematuria syndrome. Br J Urol 1982; 54: 613-15. 6. Sheil AGR, Ibels LS, Pollock C, Graham JC, Short J. Treatment of loin pain/haematuria syndrome by renal autotransplantation. Lancet 1987; ii: 907-08. 7. Chin JL. Loin pain-haematuria syndrome: role for renal transplantation. J Urol 1992; 147: 987-89. 8. Dworkin RH, Caligor E. Psychiatric diagnosis and chronic pain: DSMIII-R and beyond.J Pain Symptom Manag 1988; 3: 87-98. 9. Lipowski ZJ. Somatization and depression. Psychosomatics 1990; 31: 13-21. 5. Aber
Surveillance for small-for-gestational-age fetuses SiR,—The importance of avoiding intervention where a healthy fetus just happens to be genetically small is sensible, but Dr Almstrom and colleagues’ (Oct 17, p 936) report does not meet this aim, at least in one respect. There were 426 women in the study, of whom 242 had female and only 184 had male babies-a male/female ratio of 0-76, compared with the usual ratio of 1-05. This is obviously because the selection criterion for the study was that a scan estimated the fetus to weigh less than 2 SD below the mean for gestation at or after 31 completed weeks, and of course female babies are on average smaller than male infants at that stage of pregnancy. Had it been possible to allow for fetal sex (and assuming a population sex ratio of 1 -05) I calculate that 34 women with female fetuses would have avoided unnecessary intensive surveillance (but of course 34 additional women with male fetuses would have been offered surveillance). Presumably this would have improved the effectiveness of the intervention, though it is difficult to be certain of this since there was no non-intervention control group. Aberdeen Maternity Hospital, Aberdeen AB9 2ZA, UK
M.H.HALL
Energy supplementation during pregnancy and postnatal growth SiR,—There are two ways of reading the stimulating report by Professor Kusin and colleagues (Sept 12, p 623) and both leave us somewhat disconcerted. Their findings can indeed be interpreted as documentation for a supposed biological effect of supplementary feeding during pregnancy on postnatal growth. The effect of energy supplementation was, however, estimated from observations on less than 30% of participants (35% of enrolled women complied and for 80% of their infants sufficient data were obtained). By restricting the analysis to those subjects only, Kusin et al lost the methodological advantages of randomisation. Even though compliers and non-compliers "were similar in physiological and socioeconomic characteristics" these characteristics may have introduced confounding. Furthermore, differential self-selection
