1074
addressed an association with coronary disease risk only rather than with total mortality. Because of the need to exclude men with pre-existing disease at baseline, diseases with delayed time-todeath, such as oral cancer, would be under-represented in a follow-up of only two years. Analysis of total mortality will clearly require further follow-up. Bofetta and GarfmkeP reported that, after 12 years of follow-up of 276 802 men from the American Cancer Society Study, those consuming one drink per day had the largest reduction in overall mortality (relative risk 0-84, 95% CI 081-087) compared with non-drinkers. For CHD mortality, an inverse association with alcohol was reported even at levels of five drinks per day. Bypass surgery and angioplasty were chosen a priori to be included as a highly sensitive measure of severe atherosclerosis. The inverse trend between alcohol and non-fatal infarction was highly significant and the trend for fatal heart disease was also strongly negative (table n). Therefore, the inclusion of bypass and angioplasty as an endpoint did not artificially create an inverse association that was not already present. We did not find a U-shaped association between alcohol and CAD. This is consistent with most studies of alcohol and morbidity and mortality from CHD. The U-shaped association is generally reported for total mortality, which was not the focus of our report. The increase in overall disease risk at higher levels that others have observed is probably caused largely by the host of other complications of excessive alcohol consumption. Few men in our cohort (3-5%) drank more than 50 g per day. The 1693 men (3-8%) were lost to follow-up only for non-fatal outcomes. The entire cohort was followed up for fatal events. The baseline distribution of alcohol consumption among nonrespondents did not differ appreciably from the percentages listed in table i in our paper. For example, 38-2% of the non-respondents drank 5-30 g of alcohol per day compared with 40 2% for respondents. Adjustment for aspirin use did not materially alter the relative risks reported.
PERIPHERAL BLOOD LEUCOCYTE AND D!FFERENT!AL COUNTS, LYMPHOCYTE SUBPOPULATIONS, AND RATIO OF HELPER TO SUPPRESSOR CELLS DURING FOLLOW-UP
we
Departments of Epidemiology, Nutrition, and Biostatistics, Boston, Massachusetts 02115, USA, and Channing Laboratory, Department of Medicine, Harvard Medical School and Brigham and Women’s Boston, Massachusetts
Hospital,
ERIC B. RIMM EDWARD GIOVANNUCCI WALTER C. WILLETT GRAHAM A. COLDITZ ALBERTO ASCHERIO BERNARD ROSNER MEIR J. STAMPFER
P, Garfinkel L. Alcohol drinking and mortality among men enrolled in American Cancer Society Prospective Study. Epidemiology 1990; 1: 342-48.
1. Bofetta
an
I
I
I
*1991, t x 109/1; #°J°, reference values shown m parentheses. Measurements by Coulter Epics flow cytometer (Coulter Electronics, Hialeah, USA), and lymphocyte subpopulation analysis with direct immunofluorescence with fluorescein Isothlocyanate-conJugated monoclonal antibodies (’Coulter Clone’)
subpopulations (the CD4/CD8 ratio remaining within normal range), with a return to normal within 3 days. In view of the high frequency of appendicitis, lymphopenia is clearly uncommon and associated with the gangrenous state and not with acute infection.! Since gangrene can lead to increased infectious morbidity, the gram-negative sepsis reported here could be a causal factor in lymphopenia. In animals, gram-negative sepsis can induce leucopenia and lymphopenia within 6 h, with subsequent hyperleucocytosis and a return to normal oflymphocyte count by 48 h;3 furthermore, such infection-induced lymphopenia is associated with a transient fall in CD-cell subpopulationas we have shown here. However, how sepsis could induce lymphopenia—compartmentaJisation after endotoxin liberation’* or individual sensitivity to increased blood cortisoP-is still under debate. Department of Internal Medicine, St Luc Academic Hospital, University of Louvain Medical School, B-1200 Brussels, Belgium, and Departments of Internal Medicine and Surgery, CHBS Reine Fabiola Hospital, Sambreville
OLIVIER DEVUYST PHILIPPE MALDAGUE PIERRE FRANCOIS ROBERT DEKEULENEER JEAN-LOUIS MICHAUX
Jahangin M, Wyllie JH. Peripheral blood lymphopenia in gangrenous appendicitis. Br Med J 1990; 301: 215. 2. Lewis FR, Holcroft JW, Boey J, Dunphy JE. Appendicitis, a critical review of diagnosis and treatment in 1,000 cases. Arch Surg 1975; 110: 677-84. 3. Toth LA, Krueger JM. Hematologic effects of exposure to three infective agents in rabbits.J Am Vet Med Assoc 1989; 195: 981-86. 4. Burleson DG, Mason AD, Pruitt BA. Lymphoid subpopulation changes after thermal injury and thermal injury with infection in an experimental model. Ann Surg 1988; 1.
Time-course of
lymphopenia appendicitis
in gangrenous
SIR,-Dr Baker and colleagues (Aug 31, p 569) report peripheral blood lymphopenia associated with bowel necrosis, as previously noted in gangrenous appendicitis.’ We report such a case to show the precise time-course of the white blood cell (WBC) changes, as well as transient modifications in lymphocyte subpopulations. A 28-year-old woman with no medical history was admitted for suspected acute appendicitis (temperature 38-4OC, blood pressure 140/80 mm Hg, and pulse 110 beats per min). She had severe leucopenia, with lymphopenia and neutrophilia, on admission (1030 h) but by 1600 h she had hyperleucocytosis with a striking increase in the neutrophil count and persistent lymphopenia (table). Appendicectomy was done, and the diagnosis of gangrenous appendicitis was confirmed histologically. Two admission blood cultures, as well as culture of the appendix, were positive for Citrobacter freundii. Results of standard serological tests were repeatedly negative. Lymphopenia was corrected within 72 h of operation, and WBC count was normal during an 8-month
follow-up (table). Our results show that lymphopenia arises at the start of infection, before an increase in the neutrophil count. This could account for the initial leucopenia, and its correction within 6 h, after the striking increase in neutrophils. On the other hand, lymphopenia is characterised by decreased T-cell and relatively increased B-cell even
207: 208-12.
Laparoscopic cholecystectomy SIR,-Enthusiasts for laparoscopic cholecystectomy will be
pleased to know that The Lancet has put its stamp of approval on this surgical innovation (Sept 8 editorial). However, readers will be saddened by the last paragraph in which you suggest that the entrepreneurial surgeon remains uncontrolled. Troidl and colleagues from Cologne1 show how an academic department of the highest standing undertook such an evaluation and found that a standard trial was no longer possible; patient preference was such that randomisation could not be undertaken. My own experience was similar; in June, 1990, I submitted a detailed protocol to the Department of Health outlining a proposed trial of laparoscopic and mini-cholecystectomy, at which stage such a trial was feasible. By the time I received a reply at the end of November seeking further information, I was aware of Troidl’s views, and believed that randomisation was no longer possible. In the event, the advantages of the laparoscopic technique were by then self-evident.
1075
Because of the ability of surgeons to communicate and the rapidity with which a new technique is mastered by surgeons, the lesson to be learned from this development is that research organisations and grant-giving bodies must be able to respond quickly to these developments. They must fund early prospective studies so that new techniques will pass muster or be rejected before many organisations have spent money on expensive and inappropriate machines such as the extracorporeal shockwave biliary lithotripsy device2 or even the laser used for gallbladder dissection in laparoscopic cholecystectomy.3 Perhaps, the saddest lesson for the British surgeons has been the complete lack of a British instrument-maker to supply equipment for this operation and the hard-sell techniques of the suppliers of foreign instruments in the UK. Middlesex Hospital, London W1N 8AA, UK
R. C. G. RUSSELL
1. Neugebauer E, Troidl H, Spangenberger W, Dietrich A, Lefering R. Cholecystectomy Study Group. Conventional versus laparoscopic cholecystectomy and the randomised controlled trial Br J Surg 1991; 78: 150-54. 2. Holohan TV. Laparoscopic cholecystectomy. Lancet 1991; 338: 801-03. 3. Southern Surgeons’ Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991; 325: 1073-78.
Metal stents in Budd-Chiari syndrome SIR,-Dr Weernink and colleagues (Sept 7, p 644) report placement of a Wallstent in the hepatic vein of a patient with Budd-Chiari syndrome, with good results. We believe that this is a logical technique that deserves further investigation, and report a 40-year-old housewife whom we believe was the first to receive a Gianturco metal stent in the inferior vena cava before mesocaval shunting.’ She remains well 31years later. However, it is important to establish clearly the extent of hepatocellular damage before undertaking such a conservative procedure, lest the presence of a metal stent in the hepatic veins or inferior vena cava jeopardises liver transplantation should hepatic failure develop, especially since this latter approach to management has proved very successful. Royal Free Hospital, London NW3 2QG, UK
ROBERT DICK K. E. H. HOBBS
,
Variation of aortic compliance with age and
pressure) is given as a mean (SD) Laogun and Goshng).
Irving D, Hobbs K. Dilatation of the inferior vena cava using an expandable metal stent in Budd-Chiari syndrome. J Hepatol 1991; 13: 149-51.
Measuring aortic distensibility SIR,-Dr Dart and colleagues (Aug 3, p 270) have used a method for assessing aortic distensibility which may be prone to error. The oscillation frequency of the ultrasound probe was not provided but at 4 MHz, which is typical for echocardiography, the maximum spatial resolution would be of the same order of magnitude as the change in aortic diameter being measured. This change would be much reduced in older individuals and in patients with arterial stiffening, making accurate measurements even more difficult. The reproducibility cited implies an ability to measure changes in aortic diameter of less than half the ultrasound wavelength used. We find this surprising. If aortic distensibility is to be assessed by measuring changes in aortic diameter during the cardiac cycle the most reliable approach would be a phase-locked loop technique.1 Magnetic resonance imaging2 can also be used but is expensive and not generally available. However, a problem with such techniques is that they provide a value for distensibility of the artery at a given section. Where patients are to be monitored repeatedly, relocation of the measurement point may prove difficult. Furthermore, focal lesions are formed in atherosclerosis, and distensibility measured at the site of such a lesion would not necessarily be the same as at a neighbouring, non-atherosclerotic site, further compounding the difficulties of follow-up studies. For these reasons, one of us (R. G. G.) described in 1976 a pulse-wave velocity doppler ultrasound technique based on the determination of the average compliance (distensibility) of the
for each age range
mm Hg pulse (modified from
aortic pathway. Hirai et al4 have observed that the abdominal aorta is especially sensitive for differentiating normal subjects from paticnts with coronary artery disease. Furthermore the abdominal aorta may be affected by atherosclerosis much earlier and more intensively than other arteries.5 Measurement of arterial wall compliance over both the descending thoracic and abdominal aorta makes this technique suitable for assessing susceptibility to atheromatous arterial disease as well as for monitoring response to therapy. The reproducibility of the technique has recently been evaluated6 and the approach has been used to investigate abnormal arterial behaviour in metabolic disorders, including diabetes mellitus,’ familial hypercholesterolaemia,8and Ehlers-Danlos and Marfan’s syndromes.9 In-vivo arterial wall compliance increases sharply with age in the first decade of life, reaching a peak at around 10 years." Thereafter compliance decreases with age (figure). It is not only the distensibility of the artery that is important (Aug 3 editorial) but also the stage of life at which it is observed.
descending
Divisions of
Radiological
Sciences and Medicine,
United Medical and Dental Schools, Guy’s and St Thomas’ Hospitals, London SE1 7EH, UK 1. Hokanson
E. D. LEHMANN R. G. GOSLING
DE, Mozersky DJ, Summer DS, Strandness DE Jr. A phase-locked echo
tracking 1 Gillams A, Dick R, Plans A,
sex.
0 = male; 8 = females. Compliance (C% per 10
system for
recording
arterial diameter
changes
in
vivo. J Appl Physiol
1972; 32: 728-33.
RH, Underwood SR, Bogren HG, et al. Regional aortic compliance studied by magnetic resonance imaging: the effects of age, training and coronary artery disease. Br Heart J 1989; 62: 90-96. 3. Gosling RG. Extraction of physiological information from spectrum analysed Doppler-shifted continuous-wave ultrasound signals. In: Hill PW, Watson BW, eds. IEE modem electronics monographs. Stevenage: Peter Peregrinus, 1976; 21:
2. Mohiaddin
73-125. 4. Hirai T, Sasayama S, Kawasaki T, Yagi S. Stiffness of systemic arteries in patients with myocardial infarction. Circulation 1989; 80: 78-86. 5. Manning PJ, Clarkson TB. Development, distribution, and lipid content of diet-induced atherosclerotic lesions of rhesus monkeys. Exp Mol Pathol 1972; 17: 38-54. 6. Wright JS, Cruikshank JK, Kontis S, Dore C, Gosling RG. Aortic compliance measured by non-invasive Doppler ultrasound: description of a method and its reproducibility. Clin Sci 1990; 78: 463-68. 7. Wahlqvist ML, Lo CS, Myers KA. Fish intake and arterial wall characteristics in healthy people and diabetic patients. Lancet 1989; ii: 944-46. 8. Lehmann ED, Fatemi-Langroudi B, Watts GF, Gosling RG. Arterial wall compliance in type I diabetes mellitus and familial hypercholesterolaemia. Diabetologia 1991; 34 (suppl 2): A166. 9. Handler CE, Child A, Light NM. Mitral valve prolapse, aortic compliance, and skin collagen in joint hypermobility syndrome. Br Heart J 1985; 54: 501-08. 10. Laogun AA, Gosling RG. In vivo arterial compliance in man. Clin Phys Physiol Meas 1982; 3: 201-12.
Injected corticosteroids in refractory asthma SIR,-We read your Aug 24 editorial (p 479) with concern and would advise caution about the interpretation of Ogirala and colleagues’ study of high-dose intramuscular triamcinolone acetonide (TA) in chronic severe asthma.1 The conclusion that high-dose TA was more effective than low-dose prednisolone was hardly surprising. TA is 10-15 times more potent than prednisolone in adrenalectomised rats, a "steroid sensitive" model, and may be more potent still in man, who is "steroid resistant".22
addressed an association with coronary disease risk only rather than with total mortality. Because of the need to exclude men with pre-existing disease at baseline, diseases with delayed time-todeath, such as oral cancer, would be under-represented in a follow-up of only two years. Analysis of total mortality will clearly require further follow-up. Bofetta and GarfmkeP reported that, after 12 years of follow-up of 276 802 men from the American Cancer Society Study, those consuming one drink per day had the largest reduction in overall mortality (relative risk 0-84, 95% CI 081-087) compared with non-drinkers. For CHD mortality, an inverse association with alcohol was reported even at levels of five drinks per day. Bypass surgery and angioplasty were chosen a priori to be included as a highly sensitive measure of severe atherosclerosis. The inverse trend between alcohol and non-fatal infarction was highly significant and the trend for fatal heart disease was also strongly negative (table n). Therefore, the inclusion of bypass and angioplasty as an endpoint did not artificially create an inverse association that was not already present. We did not find a U-shaped association between alcohol and CAD. This is consistent with most studies of alcohol and morbidity and mortality from CHD. The U-shaped association is generally reported for total mortality, which was not the focus of our report. The increase in overall disease risk at higher levels that others have observed is probably caused largely by the host of other complications of excessive alcohol consumption. Few men in our cohort (3-5%) drank more than 50 g per day. The 1693 men (3-8%) were lost to follow-up only for non-fatal outcomes. The entire cohort was followed up for fatal events. The baseline distribution of alcohol consumption among nonrespondents did not differ appreciably from the percentages listed in table i in our paper. For example, 38-2% of the non-respondents drank 5-30 g of alcohol per day compared with 40 2% for respondents. Adjustment for aspirin use did not materially alter the relative risks reported.
PERIPHERAL BLOOD LEUCOCYTE AND D!FFERENT!AL COUNTS, LYMPHOCYTE SUBPOPULATIONS, AND RATIO OF HELPER TO SUPPRESSOR CELLS DURING FOLLOW-UP
we
Departments of Epidemiology, Nutrition, and Biostatistics, Boston, Massachusetts 02115, USA, and Channing Laboratory, Department of Medicine, Harvard Medical School and Brigham and Women’s Boston, Massachusetts
Hospital,
ERIC B. RIMM EDWARD GIOVANNUCCI WALTER C. WILLETT GRAHAM A. COLDITZ ALBERTO ASCHERIO BERNARD ROSNER MEIR J. STAMPFER
P, Garfinkel L. Alcohol drinking and mortality among men enrolled in American Cancer Society Prospective Study. Epidemiology 1990; 1: 342-48.
1. Bofetta
an
I
I
I
*1991, t x 109/1; #°J°, reference values shown m parentheses. Measurements by Coulter Epics flow cytometer (Coulter Electronics, Hialeah, USA), and lymphocyte subpopulation analysis with direct immunofluorescence with fluorescein Isothlocyanate-conJugated monoclonal antibodies (’Coulter Clone’)
subpopulations (the CD4/CD8 ratio remaining within normal range), with a return to normal within 3 days. In view of the high frequency of appendicitis, lymphopenia is clearly uncommon and associated with the gangrenous state and not with acute infection.! Since gangrene can lead to increased infectious morbidity, the gram-negative sepsis reported here could be a causal factor in lymphopenia. In animals, gram-negative sepsis can induce leucopenia and lymphopenia within 6 h, with subsequent hyperleucocytosis and a return to normal oflymphocyte count by 48 h;3 furthermore, such infection-induced lymphopenia is associated with a transient fall in CD-cell subpopulationas we have shown here. However, how sepsis could induce lymphopenia—compartmentaJisation after endotoxin liberation’* or individual sensitivity to increased blood cortisoP-is still under debate. Department of Internal Medicine, St Luc Academic Hospital, University of Louvain Medical School, B-1200 Brussels, Belgium, and Departments of Internal Medicine and Surgery, CHBS Reine Fabiola Hospital, Sambreville
OLIVIER DEVUYST PHILIPPE MALDAGUE PIERRE FRANCOIS ROBERT DEKEULENEER JEAN-LOUIS MICHAUX
Jahangin M, Wyllie JH. Peripheral blood lymphopenia in gangrenous appendicitis. Br Med J 1990; 301: 215. 2. Lewis FR, Holcroft JW, Boey J, Dunphy JE. Appendicitis, a critical review of diagnosis and treatment in 1,000 cases. Arch Surg 1975; 110: 677-84. 3. Toth LA, Krueger JM. Hematologic effects of exposure to three infective agents in rabbits.J Am Vet Med Assoc 1989; 195: 981-86. 4. Burleson DG, Mason AD, Pruitt BA. Lymphoid subpopulation changes after thermal injury and thermal injury with infection in an experimental model. Ann Surg 1988; 1.
Time-course of
lymphopenia appendicitis
in gangrenous
SIR,-Dr Baker and colleagues (Aug 31, p 569) report peripheral blood lymphopenia associated with bowel necrosis, as previously noted in gangrenous appendicitis.’ We report such a case to show the precise time-course of the white blood cell (WBC) changes, as well as transient modifications in lymphocyte subpopulations. A 28-year-old woman with no medical history was admitted for suspected acute appendicitis (temperature 38-4OC, blood pressure 140/80 mm Hg, and pulse 110 beats per min). She had severe leucopenia, with lymphopenia and neutrophilia, on admission (1030 h) but by 1600 h she had hyperleucocytosis with a striking increase in the neutrophil count and persistent lymphopenia (table). Appendicectomy was done, and the diagnosis of gangrenous appendicitis was confirmed histologically. Two admission blood cultures, as well as culture of the appendix, were positive for Citrobacter freundii. Results of standard serological tests were repeatedly negative. Lymphopenia was corrected within 72 h of operation, and WBC count was normal during an 8-month
follow-up (table). Our results show that lymphopenia arises at the start of infection, before an increase in the neutrophil count. This could account for the initial leucopenia, and its correction within 6 h, after the striking increase in neutrophils. On the other hand, lymphopenia is characterised by decreased T-cell and relatively increased B-cell even
207: 208-12.
Laparoscopic cholecystectomy SIR,-Enthusiasts for laparoscopic cholecystectomy will be
pleased to know that The Lancet has put its stamp of approval on this surgical innovation (Sept 8 editorial). However, readers will be saddened by the last paragraph in which you suggest that the entrepreneurial surgeon remains uncontrolled. Troidl and colleagues from Cologne1 show how an academic department of the highest standing undertook such an evaluation and found that a standard trial was no longer possible; patient preference was such that randomisation could not be undertaken. My own experience was similar; in June, 1990, I submitted a detailed protocol to the Department of Health outlining a proposed trial of laparoscopic and mini-cholecystectomy, at which stage such a trial was feasible. By the time I received a reply at the end of November seeking further information, I was aware of Troidl’s views, and believed that randomisation was no longer possible. In the event, the advantages of the laparoscopic technique were by then self-evident.
1075
Because of the ability of surgeons to communicate and the rapidity with which a new technique is mastered by surgeons, the lesson to be learned from this development is that research organisations and grant-giving bodies must be able to respond quickly to these developments. They must fund early prospective studies so that new techniques will pass muster or be rejected before many organisations have spent money on expensive and inappropriate machines such as the extracorporeal shockwave biliary lithotripsy device2 or even the laser used for gallbladder dissection in laparoscopic cholecystectomy.3 Perhaps, the saddest lesson for the British surgeons has been the complete lack of a British instrument-maker to supply equipment for this operation and the hard-sell techniques of the suppliers of foreign instruments in the UK. Middlesex Hospital, London W1N 8AA, UK
R. C. G. RUSSELL
1. Neugebauer E, Troidl H, Spangenberger W, Dietrich A, Lefering R. Cholecystectomy Study Group. Conventional versus laparoscopic cholecystectomy and the randomised controlled trial Br J Surg 1991; 78: 150-54. 2. Holohan TV. Laparoscopic cholecystectomy. Lancet 1991; 338: 801-03. 3. Southern Surgeons’ Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991; 325: 1073-78.
Metal stents in Budd-Chiari syndrome SIR,-Dr Weernink and colleagues (Sept 7, p 644) report placement of a Wallstent in the hepatic vein of a patient with Budd-Chiari syndrome, with good results. We believe that this is a logical technique that deserves further investigation, and report a 40-year-old housewife whom we believe was the first to receive a Gianturco metal stent in the inferior vena cava before mesocaval shunting.’ She remains well 31years later. However, it is important to establish clearly the extent of hepatocellular damage before undertaking such a conservative procedure, lest the presence of a metal stent in the hepatic veins or inferior vena cava jeopardises liver transplantation should hepatic failure develop, especially since this latter approach to management has proved very successful. Royal Free Hospital, London NW3 2QG, UK
ROBERT DICK K. E. H. HOBBS
,
Variation of aortic compliance with age and
pressure) is given as a mean (SD) Laogun and Goshng).
Irving D, Hobbs K. Dilatation of the inferior vena cava using an expandable metal stent in Budd-Chiari syndrome. J Hepatol 1991; 13: 149-51.
Measuring aortic distensibility SIR,-Dr Dart and colleagues (Aug 3, p 270) have used a method for assessing aortic distensibility which may be prone to error. The oscillation frequency of the ultrasound probe was not provided but at 4 MHz, which is typical for echocardiography, the maximum spatial resolution would be of the same order of magnitude as the change in aortic diameter being measured. This change would be much reduced in older individuals and in patients with arterial stiffening, making accurate measurements even more difficult. The reproducibility cited implies an ability to measure changes in aortic diameter of less than half the ultrasound wavelength used. We find this surprising. If aortic distensibility is to be assessed by measuring changes in aortic diameter during the cardiac cycle the most reliable approach would be a phase-locked loop technique.1 Magnetic resonance imaging2 can also be used but is expensive and not generally available. However, a problem with such techniques is that they provide a value for distensibility of the artery at a given section. Where patients are to be monitored repeatedly, relocation of the measurement point may prove difficult. Furthermore, focal lesions are formed in atherosclerosis, and distensibility measured at the site of such a lesion would not necessarily be the same as at a neighbouring, non-atherosclerotic site, further compounding the difficulties of follow-up studies. For these reasons, one of us (R. G. G.) described in 1976 a pulse-wave velocity doppler ultrasound technique based on the determination of the average compliance (distensibility) of the
for each age range
mm Hg pulse (modified from
aortic pathway. Hirai et al4 have observed that the abdominal aorta is especially sensitive for differentiating normal subjects from paticnts with coronary artery disease. Furthermore the abdominal aorta may be affected by atherosclerosis much earlier and more intensively than other arteries.5 Measurement of arterial wall compliance over both the descending thoracic and abdominal aorta makes this technique suitable for assessing susceptibility to atheromatous arterial disease as well as for monitoring response to therapy. The reproducibility of the technique has recently been evaluated6 and the approach has been used to investigate abnormal arterial behaviour in metabolic disorders, including diabetes mellitus,’ familial hypercholesterolaemia,8and Ehlers-Danlos and Marfan’s syndromes.9 In-vivo arterial wall compliance increases sharply with age in the first decade of life, reaching a peak at around 10 years." Thereafter compliance decreases with age (figure). It is not only the distensibility of the artery that is important (Aug 3 editorial) but also the stage of life at which it is observed.
descending
Divisions of
Radiological
Sciences and Medicine,
United Medical and Dental Schools, Guy’s and St Thomas’ Hospitals, London SE1 7EH, UK 1. Hokanson
E. D. LEHMANN R. G. GOSLING
DE, Mozersky DJ, Summer DS, Strandness DE Jr. A phase-locked echo
tracking 1 Gillams A, Dick R, Plans A,
sex.
0 = male; 8 = females. Compliance (C% per 10
system for
recording
arterial diameter
changes
in
vivo. J Appl Physiol
1972; 32: 728-33.
RH, Underwood SR, Bogren HG, et al. Regional aortic compliance studied by magnetic resonance imaging: the effects of age, training and coronary artery disease. Br Heart J 1989; 62: 90-96. 3. Gosling RG. Extraction of physiological information from spectrum analysed Doppler-shifted continuous-wave ultrasound signals. In: Hill PW, Watson BW, eds. IEE modem electronics monographs. Stevenage: Peter Peregrinus, 1976; 21:
2. Mohiaddin
73-125. 4. Hirai T, Sasayama S, Kawasaki T, Yagi S. Stiffness of systemic arteries in patients with myocardial infarction. Circulation 1989; 80: 78-86. 5. Manning PJ, Clarkson TB. Development, distribution, and lipid content of diet-induced atherosclerotic lesions of rhesus monkeys. Exp Mol Pathol 1972; 17: 38-54. 6. Wright JS, Cruikshank JK, Kontis S, Dore C, Gosling RG. Aortic compliance measured by non-invasive Doppler ultrasound: description of a method and its reproducibility. Clin Sci 1990; 78: 463-68. 7. Wahlqvist ML, Lo CS, Myers KA. Fish intake and arterial wall characteristics in healthy people and diabetic patients. Lancet 1989; ii: 944-46. 8. Lehmann ED, Fatemi-Langroudi B, Watts GF, Gosling RG. Arterial wall compliance in type I diabetes mellitus and familial hypercholesterolaemia. Diabetologia 1991; 34 (suppl 2): A166. 9. Handler CE, Child A, Light NM. Mitral valve prolapse, aortic compliance, and skin collagen in joint hypermobility syndrome. Br Heart J 1985; 54: 501-08. 10. Laogun AA, Gosling RG. In vivo arterial compliance in man. Clin Phys Physiol Meas 1982; 3: 201-12.
Injected corticosteroids in refractory asthma SIR,-We read your Aug 24 editorial (p 479) with concern and would advise caution about the interpretation of Ogirala and colleagues’ study of high-dose intramuscular triamcinolone acetonide (TA) in chronic severe asthma.1 The conclusion that high-dose TA was more effective than low-dose prednisolone was hardly surprising. TA is 10-15 times more potent than prednisolone in adrenalectomised rats, a "steroid sensitive" model, and may be more potent still in man, who is "steroid resistant".22
