CORRESPON DENCE
Hemolytic-uremic syndrome
of hyperestrogenism;' and HUS occurring after an endotoxic condition, such as typhoid fever,6 may be related to endotoxic activation of the proteolytic coagulation and complement cascades, together with release of tissue proteases from damaged cells. It would be consistent with this interpretation if the illnesses preceding HUS in childhood increased the proteolytic load significantly. Susceptibility would rest on cellular enzyme content, lysosomal lability and the ability to mount a response of effective proteolytic inhibitors.
To the editor: Drs. B.S. Kaplan and 1.-P. de Chadar.vian (Can Med Assoc 1 117: 1246, 1977) have emphasized the usefulness of recognizing overlapping features in the closely related syndromes of hemolytic-uremic syndrome (HUS), thrombotic thrombocytopenic purpura and malignant hypertension, and have suggested "endothelial damage as the primary and major event". However, something more fundamental about the pathogenesis of HUS may be deduced by defining further what is common to the otherwise disparate J.M. STARK, MD, FRC PATH circumstances preceding the synDepartment of medical microbiology drome. Welsh National school of medicine Heath Park, Cardiff HUS may be regarded as the end Wales result of a major loss of control within the linked system of proteo- References lytic inhibitors.1 Each predisposing or N, HAUPT H, ScIIwIcK precipitating condition contains an 1. HEIMBURGER inhibitors of human HG: Proteinase element of proteolytic stress; if this plasma, in Proceedings of the Interbecomes overwhelming, several pronational Research Conference on Proteolytic cascades, including the comteinase Inhibitors, FRITZ H, TCHESCHE H (eds), Walter de Gruyter, Berlin, plement, coagulation and renin cas1971, pp 1-21 cades, may be released from control. 2. STARK JM: Disequilibrium in control The case for this in pre-eclampsia of proteolysis as a cause of prehas been argued elsewhere2 and of eclampsia. Lancet 1: 417, 1978 course HUS may develop in severe 3. PRITCHARD JA, WEISMAN R JR, RATNOFF OD, et al: Intravascular hemopre-eclampsia? The same mechanism lysis, thrombocytopenia and other hecan be recognized in other prodromal matologic abnormalities associated conditions. Thus, postpartum HUS with severe toxemia of pregnancy. N may be related to the intense involuEngi J Med 250: 89, 1954 tional proteolysis of the puerperium;4 4. SCHOOLWERTH AC, SANDLER RS, KLAHR 5, et al: Nephrosclerosis postHUS developing in young women partum and in women taking oral taking estrogen-containing oral concontraceptives. A report of two cases. traceptives may be related to proArch Intern Med 136: 178, 1976 tease-dependent acute-phase effects 5. LAURELL GB, SKANSE B: Estrogens and plasma orosomucoid. I Gun Endocrinol Metab 23: 214, 1963 contributions to the correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
6. BAKER NM, MILLs AE, RACHMAN I,
et al: Haemolytic uraemic syndrome in typhoid fever. Br Med 1 2: 84, 1974
Foot problems and their management To the editor: We would like to make a plea for a more careful look at the foot; we believe it is a neglected area in medicine. Sometimes this neglect is simply due to a lack of knowledge, but we think it more often stems from a lack of interest. Dr. Melvin Jahss,1 associate clinical professor of orthopedic surgery at Mount Sinai school of medicine in New York, has shown that this opinion is shared by others: The general practitioner as well as the orthopedic surgeon has little interest or knowledge and has shunned responsibility in this field. There are at most three or four orthopedic programs throughout the country that make a serious attempt to teach foot pathology either at the undergraduate or graduate level. There is not one full time orthopedic residency training program on the foot. There is only one orthopedic foot fellowship available and the position has remained vacant. The American Boards ask but one or two token questions a year about the adult foot, and yet the average orthopedic surgeon devotes approximately 20% of his practice to foot problems and foot surgery. The foot is not even mentioned by the American Board as a specific area of interest and competency. Although Dr. Jahss's comments are based on experience in the United States, we believe the same conditions exist in Canada. It seems that the lowly foot, so important to each of us, has not merited our fullest consideration. The treatment of simple foot problems, such as ingrown toenails, warts and calluses, is taught only superficially in our medical schools. In
CMA JOURNAL/JUNE 10, 1978/VOL. 118 1353
Hemolytic-uremic syndrome
of hyperestrogenism;' and HUS occurring after an endotoxic condition, such as typhoid fever,6 may be related to endotoxic activation of the proteolytic coagulation and complement cascades, together with release of tissue proteases from damaged cells. It would be consistent with this interpretation if the illnesses preceding HUS in childhood increased the proteolytic load significantly. Susceptibility would rest on cellular enzyme content, lysosomal lability and the ability to mount a response of effective proteolytic inhibitors.
To the editor: Drs. B.S. Kaplan and 1.-P. de Chadar.vian (Can Med Assoc 1 117: 1246, 1977) have emphasized the usefulness of recognizing overlapping features in the closely related syndromes of hemolytic-uremic syndrome (HUS), thrombotic thrombocytopenic purpura and malignant hypertension, and have suggested "endothelial damage as the primary and major event". However, something more fundamental about the pathogenesis of HUS may be deduced by defining further what is common to the otherwise disparate J.M. STARK, MD, FRC PATH circumstances preceding the synDepartment of medical microbiology drome. Welsh National school of medicine Heath Park, Cardiff HUS may be regarded as the end Wales result of a major loss of control within the linked system of proteo- References lytic inhibitors.1 Each predisposing or N, HAUPT H, ScIIwIcK precipitating condition contains an 1. HEIMBURGER inhibitors of human HG: Proteinase element of proteolytic stress; if this plasma, in Proceedings of the Interbecomes overwhelming, several pronational Research Conference on Proteolytic cascades, including the comteinase Inhibitors, FRITZ H, TCHESCHE H (eds), Walter de Gruyter, Berlin, plement, coagulation and renin cas1971, pp 1-21 cades, may be released from control. 2. STARK JM: Disequilibrium in control The case for this in pre-eclampsia of proteolysis as a cause of prehas been argued elsewhere2 and of eclampsia. Lancet 1: 417, 1978 course HUS may develop in severe 3. PRITCHARD JA, WEISMAN R JR, RATNOFF OD, et al: Intravascular hemopre-eclampsia? The same mechanism lysis, thrombocytopenia and other hecan be recognized in other prodromal matologic abnormalities associated conditions. Thus, postpartum HUS with severe toxemia of pregnancy. N may be related to the intense involuEngi J Med 250: 89, 1954 tional proteolysis of the puerperium;4 4. SCHOOLWERTH AC, SANDLER RS, KLAHR 5, et al: Nephrosclerosis postHUS developing in young women partum and in women taking oral taking estrogen-containing oral concontraceptives. A report of two cases. traceptives may be related to proArch Intern Med 136: 178, 1976 tease-dependent acute-phase effects 5. LAURELL GB, SKANSE B: Estrogens and plasma orosomucoid. I Gun Endocrinol Metab 23: 214, 1963 contributions to the correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
6. BAKER NM, MILLs AE, RACHMAN I,
et al: Haemolytic uraemic syndrome in typhoid fever. Br Med 1 2: 84, 1974
Foot problems and their management To the editor: We would like to make a plea for a more careful look at the foot; we believe it is a neglected area in medicine. Sometimes this neglect is simply due to a lack of knowledge, but we think it more often stems from a lack of interest. Dr. Melvin Jahss,1 associate clinical professor of orthopedic surgery at Mount Sinai school of medicine in New York, has shown that this opinion is shared by others: The general practitioner as well as the orthopedic surgeon has little interest or knowledge and has shunned responsibility in this field. There are at most three or four orthopedic programs throughout the country that make a serious attempt to teach foot pathology either at the undergraduate or graduate level. There is not one full time orthopedic residency training program on the foot. There is only one orthopedic foot fellowship available and the position has remained vacant. The American Boards ask but one or two token questions a year about the adult foot, and yet the average orthopedic surgeon devotes approximately 20% of his practice to foot problems and foot surgery. The foot is not even mentioned by the American Board as a specific area of interest and competency. Although Dr. Jahss's comments are based on experience in the United States, we believe the same conditions exist in Canada. It seems that the lowly foot, so important to each of us, has not merited our fullest consideration. The treatment of simple foot problems, such as ingrown toenails, warts and calluses, is taught only superficially in our medical schools. In
CMA JOURNAL/JUNE 10, 1978/VOL. 118 1353
