384
Journal of the Royal Society of Medicine Volume 84 June 1991
References 1 Payne-James J, de Gara C, Grimble G, et al Nutritional support in hospitals in the United Kingdom: National Survey 1988. Health Trends 1990;22:9-13 2 Jaeger HJ, Kerin MJ, Couse NF, Mitchell CJ, MacFie J. Prospective randomised study comparing 12 hourly and continuous administration of peripheral parenteral nutrition. Clin Nutr 1990;9(suppl 1):P115 3 Madan M, Alexander DJ, McMahon MJ. Delivery of high osmolality intravenous parenteral nutrition peripherally via an ultra fine-bore silicone catheter: a randomised study. Clin Nutr 1990;9(suppl l):P121 4 Kohlhardt SR, Smith RC. Fine-bore silicone catheters for peripheral intravenous nutrition in adults. BMJ 1989; 299:1380-1 5 Payne-James JJ, Roger J, Bray J, Rana S, McSwiggan D, Silk DBA. Comparison of polyurethane and polytetrafluorethylene peripheral venous cannulas in the development of thrombophlebitis: a randomised double-blind study. Clin Nutr 1990;9(suppl l):P117 6 Madan M, Alexander DJ, McMahon MJ. Randomised study of the effect of osmolality, heparin and hydrocortisone in peripheral intravenous nutrition. Clin Nutr 1990;9(suppl l):P122 7 Nystrom B, Olesen Larsen S, Dankert J, et aL Bactersemia in surgical patients with intravenous devices: A European multicentre incidence study. J Hosp Infect 1983;4:338-49
Homo sapiens - a species too successful However Dr Gordon Booth (December 1990 JRSM, p 757) may lament the fact the world is over populated, there is nothing that he can do about it except to eliminate himself, or, if of the appropriate age, not to father children. To persuade others to do what one is not prepared to do oneself is neither feasible nor moral and smacks of biological arrogance. J A DAVIS 1 Cambridge Road Great Shelford
Cambridge CB2 5JE
The author replies below: I was under the impression that the ancient custom by which messengers bearing bad or unwelcome news were forthwith executed without any reference to the veracity (or otherwise) of this news had fallen into
abeyance. However, I would like to point out that I am not a 'lone voice crying out in the wilderness' but a minor but involved reporter of an already very large body of well informed opinion which is becoming progressively more vocal and documented. Perhaps Professor Davis would care to read two very important and authoritative (and very well documented) publications which appeared long after my submitting my essay for publication. The first, in which my conclusions were closely mirrored, is by G C Daily and P R Ehrlich, entitled 'Rapid Climate Change and the World Food Situation'(Proc R Soc Lond [Biol] 1990;241:232-44) and the second by Professor Martin Parry is a book entitled Climate Change and World Agriculture, a UN publication produced by Earthscan Publications Ltd, London 1990, which most effectively rules out any possibility of a 100% increase in world food production, short or long term. The symptoms of the problem are numerous and clear; the diagnosis is unambiguous; the prognosis without treatment is appalling; but the potential for and nature of timely treatments, is most unclear. R GORDON BOOTH
19 Homewood Road St Albans, Herts ALl 4BG
Hormone replacement therapy We wish to comment on the article by Wallace et al. (November 1990 JRSM, p 699). The authors are wrong to state that HRT may be oflittle value after age 70 years; ample evidence exists suggesting that HRT in elderly women with osteoporosis will prevent, and to some extent reverse, bone loss1'3. Intolerance to HRT is due to side-effects, and in elderly women these are primarily the progestininduced withdrawal bleed and oestrogen-induced breast tenderness. The former may be overcome using continuous combined oestrogen and progestin administration3 and the latter by initiating therapy with oestrogen at a very low dose and increasing to a bone conserving dose after 4-6 weeks. We would consider many of the so-called contraindications to be active indication for HRT. There is now strong evidence that HRT actually decreases the risk of ischaemic heart disease and cerebrovascular disease in postmenopausal women4'5 and these additional long-term benefits of HRT should have been emphasized to the patients. Furthermore, there is no increased risk of thromboembolism with the natural oestrogens used in HRT6. Whilst hypertension should be properly controlled before initiating HRT, HRT itself usually produces a slight fall in blood pressure in most patients7. Antihypertensive agents may be administered concurrently. Since 10% of patients objected to taking tablets, transdermal patches or subcutaneous implants should also have been offered. Premenstrual tension and bloating can occur with levonorgestrel, the progestogen in Prempak-C. However, it is often possible to reduce or even overcome these side effects by prescribing an alternative progestogen. In our experience, the uptake of HRT in women of this age group is high, providing that suitable counselling is given and appropriate clinical management is employed to deal with any initial problems that may arise. M C ELLERINGTON',2 'Menopause Clinic King's College School of M I WHITEHEAD1 Medicine and Dentistry J C STEVENSON2 2Wynn Institute for Metabolic Research London NW8 9SQ
References 1 Quigley MET, Martin PL, Burnier AM, Brooks P. Estrogen therapy arrests bone loss in elderly women. Am J Obstet Gynecol 1987;156:1515-23 2 Lidsay R, Tohme JF. Estrogen treatment of patients with established osteoporosis. Obstet Gynecol 1990;76:290-5 3 Christiansen C, Riis RJ. 17B-estradiol and continuous norethisterone: a unique treatment for established osteoporosis in elderly women. J Clin Endocrinol Metab
1990;71:836-41 4 Knopp RH. The effects of postmenopausal oestrogen therapy on the incidence of arteriosclerotic vascular
disease. Obstet Gynecol 1988;72:235-305
5
Pagm-H;11 A, Ross RK, Hendersn BE. Potenopausal
oestrogen treatment and stroke: a propective study. BMJ 1988-,297:519-22 6 Boso Collaborative Drug Surveillance Programme: surgiosily confirmed gall bladder disease, venous thromboembolism and breast tumours in relation to postmenopausal estrogen therapy. N Engi J-Med 1974;200:15 7 Campbell S, Whitehead MI. Qestrogen therapy and the menopausal syndrome. Clin Obstet Gynsecol 1977;4:31-47
Journal of the Royal Society of Medicine Volume 84 June 1991
References 1 Payne-James J, de Gara C, Grimble G, et al Nutritional support in hospitals in the United Kingdom: National Survey 1988. Health Trends 1990;22:9-13 2 Jaeger HJ, Kerin MJ, Couse NF, Mitchell CJ, MacFie J. Prospective randomised study comparing 12 hourly and continuous administration of peripheral parenteral nutrition. Clin Nutr 1990;9(suppl 1):P115 3 Madan M, Alexander DJ, McMahon MJ. Delivery of high osmolality intravenous parenteral nutrition peripherally via an ultra fine-bore silicone catheter: a randomised study. Clin Nutr 1990;9(suppl l):P121 4 Kohlhardt SR, Smith RC. Fine-bore silicone catheters for peripheral intravenous nutrition in adults. BMJ 1989; 299:1380-1 5 Payne-James JJ, Roger J, Bray J, Rana S, McSwiggan D, Silk DBA. Comparison of polyurethane and polytetrafluorethylene peripheral venous cannulas in the development of thrombophlebitis: a randomised double-blind study. Clin Nutr 1990;9(suppl l):P117 6 Madan M, Alexander DJ, McMahon MJ. Randomised study of the effect of osmolality, heparin and hydrocortisone in peripheral intravenous nutrition. Clin Nutr 1990;9(suppl l):P122 7 Nystrom B, Olesen Larsen S, Dankert J, et aL Bactersemia in surgical patients with intravenous devices: A European multicentre incidence study. J Hosp Infect 1983;4:338-49
Homo sapiens - a species too successful However Dr Gordon Booth (December 1990 JRSM, p 757) may lament the fact the world is over populated, there is nothing that he can do about it except to eliminate himself, or, if of the appropriate age, not to father children. To persuade others to do what one is not prepared to do oneself is neither feasible nor moral and smacks of biological arrogance. J A DAVIS 1 Cambridge Road Great Shelford
Cambridge CB2 5JE
The author replies below: I was under the impression that the ancient custom by which messengers bearing bad or unwelcome news were forthwith executed without any reference to the veracity (or otherwise) of this news had fallen into
abeyance. However, I would like to point out that I am not a 'lone voice crying out in the wilderness' but a minor but involved reporter of an already very large body of well informed opinion which is becoming progressively more vocal and documented. Perhaps Professor Davis would care to read two very important and authoritative (and very well documented) publications which appeared long after my submitting my essay for publication. The first, in which my conclusions were closely mirrored, is by G C Daily and P R Ehrlich, entitled 'Rapid Climate Change and the World Food Situation'(Proc R Soc Lond [Biol] 1990;241:232-44) and the second by Professor Martin Parry is a book entitled Climate Change and World Agriculture, a UN publication produced by Earthscan Publications Ltd, London 1990, which most effectively rules out any possibility of a 100% increase in world food production, short or long term. The symptoms of the problem are numerous and clear; the diagnosis is unambiguous; the prognosis without treatment is appalling; but the potential for and nature of timely treatments, is most unclear. R GORDON BOOTH
19 Homewood Road St Albans, Herts ALl 4BG
Hormone replacement therapy We wish to comment on the article by Wallace et al. (November 1990 JRSM, p 699). The authors are wrong to state that HRT may be oflittle value after age 70 years; ample evidence exists suggesting that HRT in elderly women with osteoporosis will prevent, and to some extent reverse, bone loss1'3. Intolerance to HRT is due to side-effects, and in elderly women these are primarily the progestininduced withdrawal bleed and oestrogen-induced breast tenderness. The former may be overcome using continuous combined oestrogen and progestin administration3 and the latter by initiating therapy with oestrogen at a very low dose and increasing to a bone conserving dose after 4-6 weeks. We would consider many of the so-called contraindications to be active indication for HRT. There is now strong evidence that HRT actually decreases the risk of ischaemic heart disease and cerebrovascular disease in postmenopausal women4'5 and these additional long-term benefits of HRT should have been emphasized to the patients. Furthermore, there is no increased risk of thromboembolism with the natural oestrogens used in HRT6. Whilst hypertension should be properly controlled before initiating HRT, HRT itself usually produces a slight fall in blood pressure in most patients7. Antihypertensive agents may be administered concurrently. Since 10% of patients objected to taking tablets, transdermal patches or subcutaneous implants should also have been offered. Premenstrual tension and bloating can occur with levonorgestrel, the progestogen in Prempak-C. However, it is often possible to reduce or even overcome these side effects by prescribing an alternative progestogen. In our experience, the uptake of HRT in women of this age group is high, providing that suitable counselling is given and appropriate clinical management is employed to deal with any initial problems that may arise. M C ELLERINGTON',2 'Menopause Clinic King's College School of M I WHITEHEAD1 Medicine and Dentistry J C STEVENSON2 2Wynn Institute for Metabolic Research London NW8 9SQ
References 1 Quigley MET, Martin PL, Burnier AM, Brooks P. Estrogen therapy arrests bone loss in elderly women. Am J Obstet Gynecol 1987;156:1515-23 2 Lidsay R, Tohme JF. Estrogen treatment of patients with established osteoporosis. Obstet Gynecol 1990;76:290-5 3 Christiansen C, Riis RJ. 17B-estradiol and continuous norethisterone: a unique treatment for established osteoporosis in elderly women. J Clin Endocrinol Metab
1990;71:836-41 4 Knopp RH. The effects of postmenopausal oestrogen therapy on the incidence of arteriosclerotic vascular
disease. Obstet Gynecol 1988;72:235-305
5
Pagm-H;11 A, Ross RK, Hendersn BE. Potenopausal
oestrogen treatment and stroke: a propective study. BMJ 1988-,297:519-22 6 Boso Collaborative Drug Surveillance Programme: surgiosily confirmed gall bladder disease, venous thromboembolism and breast tumours in relation to postmenopausal estrogen therapy. N Engi J-Med 1974;200:15 7 Campbell S, Whitehead MI. Qestrogen therapy and the menopausal syndrome. Clin Obstet Gynsecol 1977;4:31-47
