937 self-examination. A full bladder may be differentiated from other fluid collections such as a large ovarian cyst or loculated ascites. _
St. Richard’s Hospital, Chichester, West Sussex PO19 4SE
E. C. ASHBY
Therapeutic agents cannot reach the fungus which is protected by the keratin in which it grows. Several years ago I acquired onychomycosis of nails of the right thumb and both large toes caused by Trichophyton sp. I was given griseofulvin for a year, with clearing of the thumb nail but only slight improvement in the toenails. Although symptom-free I wanted to eliminate the fungus, so
following
TRYPTOPHAN IN PATIENTS ON CHRONIC HÆMODIALYSIS
SIR,-There is increasing evidence that
low free tryptodepression. In patients on chronic hsemodiatysis, depression and even dementia have been reported.2 Dementia might be a toxic encephalopathy due to trace elements such as copper, zinc, lead, cadmium and aluminium.3-6 But we believe that the psychiatric symptoms may result from a tryptophan deficiency. a
phan concentration is associated with
SERUM TRYPTOPHAN
([Hnol/1) BEFORE AND AFTER HÆMODIALYSIS
I devised the treatment. The nail is washed with soap and water and cleaned with alcohol. Then, with a sterile 18 or 20 gauge needle, five or six holes are drilled in the nail plate, in the form of a crescent about 2 mm distal to the lunula. Anaesthesia is not necessary. However, the introduction of the needle is felt when the nail bed is reached. Cultures may be made from the powder drilled up by the needle. The holes are enlarged by dipping a round toothpick in bichloroacetic acid and drilling through the hole in the nail. When the acid reaches the nail bed a burning sensation is felt. The area also blanches as the acid reaches the fungus in the keratin. Thereafter, an ointment composed of 3% precipitated sulphur, and 3% salicylic acid in petrolatum, is applied on the affected toes each morning. A week later, five or six new holes are drilled about 2 mm distal to and between the original ones, to obtain
greater distribution of the therapeutic agent. The treatment proved effective, presumably because the therapeutic agent could reach the fungus once the protective keratin barrier was breached. If necessary, more holes could be drilled, and further applications of acid or other antifungal agents could be given. If the nail is hard and very thick, a small dental electric drill could be used. The patient should be checked frequently in order to guard against complications such as infections and reactions to the acid.
a
Worcester
City Hospital,
JACOB BREM
Worcester, Massachusetts 01610, U.S.A.
IATROGENIC POLYDIPSIA
Using the method of Denckla and Dewey, we measured total serum-tryptophan before and after dialysis in 9 patients. Initially, it was not particularly low (reference values 40-100
pmol;1), but there was a significant decrease in concentration after dialysis in all patients (see table). The patients had a standardised protein intake (40g/day) supplemented with an essential amino acid preparation (’Aminess’), which was equivalent to a mean of 1-1 .mmol tryptophan/day. We do not know if the decrease in serum-tryptophan after dialysis would have been enough to induce depression and dementia if no extra tryptophan had been given. None of the 9 patients had signs of psychiatric disturbance, but this could be due either to the dietary supplementation or to the relatively short time of dialysis, or both. of Thoracic Medicine, Karolinska Hospital, S-10401 Stockholm, Sweden
Department
Department of Medicine, Karolinska Hospital Department of Clinical Chemistry, Serafirner Hospital, Stockholm
GUNNAR UNGE LARS-ERIC LINS ERIC HULTMAN
TREATING ONYCHOMYCOSIS
StR,-Treatment for onychomycosis is not satisfactory since surgical removal of the toenails and long courses of griseofulvin are usually required. Moreover, recurrences are frequent.’ 1.Coppen, A., Eccleston, E. C., Peet, M. Lancet, 1972,ii, 1415. 2.British Medical Journal. 1976, ii. 1213 3.Flendrig, J. A., Kruis, H., Das, H. A. Lancet, 1976, i, 1235. 4.Ulmer, D.D.New Engl. J.Med. 1976, 294, 218. 5.Platts, M. M., Moorhead, P. J., Gretch, P. Lancet, 1973, ii, 159. 6.Lyle,W.H.ibid.271. 7.Denckla, W. D., Dewey, H. K. J. lab. clin. Med. 1976, 69,160.
SIR,-We describe here sive
water
and
was
a
patient with
a
variant
of compul-
drinking induced by medical advice for the treatment of nephrolithiasis. A 44-year-old post-office worker presented with complaints of excessive thirst and polyuria. 4 years previously, he had had renal colic and had been advised by his physician to increase his fluid intake. Since then he had been drinking water frequently throughout the day. Recently he had had polyuria which interfered with his daily activities, especially while on military reserve duty. During the month before admission, he was drinking every 20 min, micturating with similar frequency unable to work or travel because of his embarrassand dependence on a water supply and adjacent closet. He had nocturia several times. There were no physical findings. The osmolalities of blood and urine were 286 and 87 mosmol/kg H2O, respectively. Blood creatinine, glucose, potassium, and calcium levels were normal. During his admission the patient carefully recorded every fluid intake and urine output. He drank 9 litres by day and 2.8 litres by night and passed comparable quantities of urine. During water deprivation for 14 h, the patient’s urine output decreased and the concentration of his urine rose to 649 mosmol/kg H2O. This was also therapeutic, convincing him of his ability to moderate his fluid intake. He was advised to reduce his drinking to 2.0 litres/day. He remains well after follow-up for 9 months and is working full-time. When a patient has polydipsia and polyuria but normal renal function and glucose.and electrolyte levels, he may have diabetes insipidus or a compulsion to drink water. In this case, the latter seems more likely. The patient did not show the psychological disturbance usual in compulsive water drinking,’1 although the careful records he kept of his fluid balance sug-
ment
1. Barlow, E.
D., de Wardener, H. E. Q. Jl. Med. 1959. 28, 235.
938 gests a somewhat obsessive personality. He made no attempt cheat during fluid restriction. The patient is thus an example of iatrogenic polydipsia induced by medical instructions for the management of nephrolithiasis. to
E. M. BERRY D. HALON M. FAINARU
Department of Medicine B, Hadassah University Hospital, Jerusalem, Israel
CYCLOTRONS FOR NEUTRON THERAPY announce (Oct. 8, p. 788) that the M.R.C. cycloEdinburgh is the first in the world built solely for neutron therapy. The National Institute of Radiological Science in Chiba, Tokyo, has had a large cyclotron built specifically for neutron therapy in operation since 1973. Your news item gives the impression Europe still leads the world in neutron therapy; this is no longer so, since a dramatic cut in funding for medical cyclotrons.
SIR,-You
tron
in
C.G.R. MeV, 78530 Buc, France
R.
JEAN
Commentary from Westminster From Our Parliamentary Too Few
Dialysis
Correspondent
Machines
CONCERN about the treatment of patients with kidney disease will be aroused by the news that the Department of Health and Social Security is negotiating a cutback in the number of renal dialysis machines in the National Health Service. The financial squeeze facing the N.H.S. has led to a sharp drop in orders for new machines by hospitals and health authorities. As a result the D.H.S.S. is having to renegotiate the contracts it has with the two British companies who between them supply 90% of the machines used in the N.H.S. Since the resources for treating chronic renal failure are already regarded as grossly inadequate, this setback will be serious. Latest official estimates show that 5200 home dialysis machines and 2650 hospital machines are needed. Yet the actual numbers in use are 1389 in homes and 643 in hospitals. Each year the D.H.S.S. has to forecast the number of new machines which will be required by hospitals and health authorities-a figure which has normally worked out at just over 300. But in the past nine months there has been a fall of about 25% in the number of orders being placed as hospitals and authorities feel the squeeze tighten. Operating under the system of cash limits, they are less and less ready to commit themselves to expenditure in advance. So, despite the high priority which the D.H.S.S. would like to see given to improving these facilities, officials are now being forced to negotiate a cutback. The reluctant view is that, in the present climate, machines are much more vulnerable to the axe than staff, particularly since a dialysis machine costs- between C3500 and c4000 to buy, with additional running costs of about k6000 at home and
£9000 in hospital. At the moment dialysis services throughout the country cost about ,17 million. The Department’s reluctance to set aside special cash allocations for the machines springs from the realisation that once one specialty is given separate treatment it is hard to refuse
similar demands from other specialties. Yet Ministers remain concerned about the situation. Recently the British Kidney Patient Association was reported as saying that last year 4500 people died who could have benefited from dialysis or transplants: the estimate is that some 7500 people develop kidney failure every year. The waiting-lists for machines and transplants grow. Potential demand has increased as the medical criteria for regarding patients as suitable for treatment have widened. In 1972 a joint committee of the Royal Colleges estimated that between 23 and 29 patients per million population per year, with an upper age of 55-60, might benefit
from treatment by regular dialysis and/or transplantation. By 1975 15 new patients per million had been added to the estimate. Although the United Kingdom is slightly above the European average in the number of kidney patients under treatment by dialysis and transplantation, it lags well behind some countries. The U.K. figure at December, 1975, was 62 patients per million population compared with 56.6 for Europe. But this was less than half the figures for Switzerland (136.1), Denmark (132.4), Japan (128.9), and the United States (127). Of the nine Common Market countries, only Luxembourg and the Republic of Ireland come below Britain. Last year Mr Roland Moyle, Minister of State for Health, said he was "dissatisfied" with any aspect of the N.H.S. which failed to meet the full need. But he added: "The extent to which facilities for dialysis can be increased is for health authorities to determine, having regard to the resources available to them and in the light of guidance on priorities given by the Department". But the fear of the two British manufacturers who now supply the N.H.S. is that the D.H.S.S. may move away from a centralised purchasing system and allow individual hospitals and health authorities to buy their own machines. If this happens they believe that more machines will be imported.
Vaccination
Campaign
The Government’s national vaccination campaign launched this week by Mr David Ennals, Secretary of State for Social Services, will cost £150 000 over the next four months. This is not as much as many people would have liked to see spent on an issue which is causing great concern-the steep fall in the number of children being vaccinated.’ The initial idea was to use both Press and television for publicity, but the intention now is to concentrate on newspaper and magazine advertising, posters, and other publicity material. The campaign is aimed at parents and it is couched in simple terms, warning that polio, whooping-cough, and diphtheria can cripple and kill. The message is that thanks to vaccination these diseases have been largely wiped out, but now there is a danger of their return because many children are not being vaccinated. So parents are being urged to talk to their doctor or their health visitor or to go to their child-health clinic to discuss the matter. The Government’s aim is to dent the complacency of the public by bringing to the attention of parents the benefits that vaccination can provide. 1. See Lancet,
Oct. 22,1977, p. 884.
St. Richard’s Hospital, Chichester, West Sussex PO19 4SE
E. C. ASHBY
Therapeutic agents cannot reach the fungus which is protected by the keratin in which it grows. Several years ago I acquired onychomycosis of nails of the right thumb and both large toes caused by Trichophyton sp. I was given griseofulvin for a year, with clearing of the thumb nail but only slight improvement in the toenails. Although symptom-free I wanted to eliminate the fungus, so
following
TRYPTOPHAN IN PATIENTS ON CHRONIC HÆMODIALYSIS
SIR,-There is increasing evidence that
low free tryptodepression. In patients on chronic hsemodiatysis, depression and even dementia have been reported.2 Dementia might be a toxic encephalopathy due to trace elements such as copper, zinc, lead, cadmium and aluminium.3-6 But we believe that the psychiatric symptoms may result from a tryptophan deficiency. a
phan concentration is associated with
SERUM TRYPTOPHAN
([Hnol/1) BEFORE AND AFTER HÆMODIALYSIS
I devised the treatment. The nail is washed with soap and water and cleaned with alcohol. Then, with a sterile 18 or 20 gauge needle, five or six holes are drilled in the nail plate, in the form of a crescent about 2 mm distal to the lunula. Anaesthesia is not necessary. However, the introduction of the needle is felt when the nail bed is reached. Cultures may be made from the powder drilled up by the needle. The holes are enlarged by dipping a round toothpick in bichloroacetic acid and drilling through the hole in the nail. When the acid reaches the nail bed a burning sensation is felt. The area also blanches as the acid reaches the fungus in the keratin. Thereafter, an ointment composed of 3% precipitated sulphur, and 3% salicylic acid in petrolatum, is applied on the affected toes each morning. A week later, five or six new holes are drilled about 2 mm distal to and between the original ones, to obtain
greater distribution of the therapeutic agent. The treatment proved effective, presumably because the therapeutic agent could reach the fungus once the protective keratin barrier was breached. If necessary, more holes could be drilled, and further applications of acid or other antifungal agents could be given. If the nail is hard and very thick, a small dental electric drill could be used. The patient should be checked frequently in order to guard against complications such as infections and reactions to the acid.
a
Worcester
City Hospital,
JACOB BREM
Worcester, Massachusetts 01610, U.S.A.
IATROGENIC POLYDIPSIA
Using the method of Denckla and Dewey, we measured total serum-tryptophan before and after dialysis in 9 patients. Initially, it was not particularly low (reference values 40-100
pmol;1), but there was a significant decrease in concentration after dialysis in all patients (see table). The patients had a standardised protein intake (40g/day) supplemented with an essential amino acid preparation (’Aminess’), which was equivalent to a mean of 1-1 .mmol tryptophan/day. We do not know if the decrease in serum-tryptophan after dialysis would have been enough to induce depression and dementia if no extra tryptophan had been given. None of the 9 patients had signs of psychiatric disturbance, but this could be due either to the dietary supplementation or to the relatively short time of dialysis, or both. of Thoracic Medicine, Karolinska Hospital, S-10401 Stockholm, Sweden
Department
Department of Medicine, Karolinska Hospital Department of Clinical Chemistry, Serafirner Hospital, Stockholm
GUNNAR UNGE LARS-ERIC LINS ERIC HULTMAN
TREATING ONYCHOMYCOSIS
StR,-Treatment for onychomycosis is not satisfactory since surgical removal of the toenails and long courses of griseofulvin are usually required. Moreover, recurrences are frequent.’ 1.Coppen, A., Eccleston, E. C., Peet, M. Lancet, 1972,ii, 1415. 2.British Medical Journal. 1976, ii. 1213 3.Flendrig, J. A., Kruis, H., Das, H. A. Lancet, 1976, i, 1235. 4.Ulmer, D.D.New Engl. J.Med. 1976, 294, 218. 5.Platts, M. M., Moorhead, P. J., Gretch, P. Lancet, 1973, ii, 159. 6.Lyle,W.H.ibid.271. 7.Denckla, W. D., Dewey, H. K. J. lab. clin. Med. 1976, 69,160.
SIR,-We describe here sive
water
and
was
a
patient with
a
variant
of compul-
drinking induced by medical advice for the treatment of nephrolithiasis. A 44-year-old post-office worker presented with complaints of excessive thirst and polyuria. 4 years previously, he had had renal colic and had been advised by his physician to increase his fluid intake. Since then he had been drinking water frequently throughout the day. Recently he had had polyuria which interfered with his daily activities, especially while on military reserve duty. During the month before admission, he was drinking every 20 min, micturating with similar frequency unable to work or travel because of his embarrassand dependence on a water supply and adjacent closet. He had nocturia several times. There were no physical findings. The osmolalities of blood and urine were 286 and 87 mosmol/kg H2O, respectively. Blood creatinine, glucose, potassium, and calcium levels were normal. During his admission the patient carefully recorded every fluid intake and urine output. He drank 9 litres by day and 2.8 litres by night and passed comparable quantities of urine. During water deprivation for 14 h, the patient’s urine output decreased and the concentration of his urine rose to 649 mosmol/kg H2O. This was also therapeutic, convincing him of his ability to moderate his fluid intake. He was advised to reduce his drinking to 2.0 litres/day. He remains well after follow-up for 9 months and is working full-time. When a patient has polydipsia and polyuria but normal renal function and glucose.and electrolyte levels, he may have diabetes insipidus or a compulsion to drink water. In this case, the latter seems more likely. The patient did not show the psychological disturbance usual in compulsive water drinking,’1 although the careful records he kept of his fluid balance sug-
ment
1. Barlow, E.
D., de Wardener, H. E. Q. Jl. Med. 1959. 28, 235.
938 gests a somewhat obsessive personality. He made no attempt cheat during fluid restriction. The patient is thus an example of iatrogenic polydipsia induced by medical instructions for the management of nephrolithiasis. to
E. M. BERRY D. HALON M. FAINARU
Department of Medicine B, Hadassah University Hospital, Jerusalem, Israel
CYCLOTRONS FOR NEUTRON THERAPY announce (Oct. 8, p. 788) that the M.R.C. cycloEdinburgh is the first in the world built solely for neutron therapy. The National Institute of Radiological Science in Chiba, Tokyo, has had a large cyclotron built specifically for neutron therapy in operation since 1973. Your news item gives the impression Europe still leads the world in neutron therapy; this is no longer so, since a dramatic cut in funding for medical cyclotrons.
SIR,-You
tron
in
C.G.R. MeV, 78530 Buc, France
R.
JEAN
Commentary from Westminster From Our Parliamentary Too Few
Dialysis
Correspondent
Machines
CONCERN about the treatment of patients with kidney disease will be aroused by the news that the Department of Health and Social Security is negotiating a cutback in the number of renal dialysis machines in the National Health Service. The financial squeeze facing the N.H.S. has led to a sharp drop in orders for new machines by hospitals and health authorities. As a result the D.H.S.S. is having to renegotiate the contracts it has with the two British companies who between them supply 90% of the machines used in the N.H.S. Since the resources for treating chronic renal failure are already regarded as grossly inadequate, this setback will be serious. Latest official estimates show that 5200 home dialysis machines and 2650 hospital machines are needed. Yet the actual numbers in use are 1389 in homes and 643 in hospitals. Each year the D.H.S.S. has to forecast the number of new machines which will be required by hospitals and health authorities-a figure which has normally worked out at just over 300. But in the past nine months there has been a fall of about 25% in the number of orders being placed as hospitals and authorities feel the squeeze tighten. Operating under the system of cash limits, they are less and less ready to commit themselves to expenditure in advance. So, despite the high priority which the D.H.S.S. would like to see given to improving these facilities, officials are now being forced to negotiate a cutback. The reluctant view is that, in the present climate, machines are much more vulnerable to the axe than staff, particularly since a dialysis machine costs- between C3500 and c4000 to buy, with additional running costs of about k6000 at home and
£9000 in hospital. At the moment dialysis services throughout the country cost about ,17 million. The Department’s reluctance to set aside special cash allocations for the machines springs from the realisation that once one specialty is given separate treatment it is hard to refuse
similar demands from other specialties. Yet Ministers remain concerned about the situation. Recently the British Kidney Patient Association was reported as saying that last year 4500 people died who could have benefited from dialysis or transplants: the estimate is that some 7500 people develop kidney failure every year. The waiting-lists for machines and transplants grow. Potential demand has increased as the medical criteria for regarding patients as suitable for treatment have widened. In 1972 a joint committee of the Royal Colleges estimated that between 23 and 29 patients per million population per year, with an upper age of 55-60, might benefit
from treatment by regular dialysis and/or transplantation. By 1975 15 new patients per million had been added to the estimate. Although the United Kingdom is slightly above the European average in the number of kidney patients under treatment by dialysis and transplantation, it lags well behind some countries. The U.K. figure at December, 1975, was 62 patients per million population compared with 56.6 for Europe. But this was less than half the figures for Switzerland (136.1), Denmark (132.4), Japan (128.9), and the United States (127). Of the nine Common Market countries, only Luxembourg and the Republic of Ireland come below Britain. Last year Mr Roland Moyle, Minister of State for Health, said he was "dissatisfied" with any aspect of the N.H.S. which failed to meet the full need. But he added: "The extent to which facilities for dialysis can be increased is for health authorities to determine, having regard to the resources available to them and in the light of guidance on priorities given by the Department". But the fear of the two British manufacturers who now supply the N.H.S. is that the D.H.S.S. may move away from a centralised purchasing system and allow individual hospitals and health authorities to buy their own machines. If this happens they believe that more machines will be imported.
Vaccination
Campaign
The Government’s national vaccination campaign launched this week by Mr David Ennals, Secretary of State for Social Services, will cost £150 000 over the next four months. This is not as much as many people would have liked to see spent on an issue which is causing great concern-the steep fall in the number of children being vaccinated.’ The initial idea was to use both Press and television for publicity, but the intention now is to concentrate on newspaper and magazine advertising, posters, and other publicity material. The campaign is aimed at parents and it is couched in simple terms, warning that polio, whooping-cough, and diphtheria can cripple and kill. The message is that thanks to vaccination these diseases have been largely wiped out, but now there is a danger of their return because many children are not being vaccinated. So parents are being urged to talk to their doctor or their health visitor or to go to their child-health clinic to discuss the matter. The Government’s aim is to dent the complacency of the public by bringing to the attention of parents the benefits that vaccination can provide. 1. See Lancet,
Oct. 22,1977, p. 884.
