41 These studies5 were supported by a Special Project grant from the Council for Tobacco Research-U.S.A., Inc. The Wharton School, Regional Science Department, RICHARD J. HICKEY University of Pennsylvania, RICHARD C. CLELLAND Philadelphia, DAVID E. BOYCE. U.S.A. Pennsylvania 19174, Biology Department, Community College of Philadelphia, Philadelphia, EVELYN J. BOWERS. Pennsylvania 19103, U.S.A.

Japan and Australia. The dividing line between " heavy (highest quartile) and " normal " middle-aged Japanese males a decade ago, 5 ft. 7 in. (170 cm.) in height, was less than 132 lb. (60 kg.). There may well have been too few individuals in that group with weight and serum-cholesterol of sufficient magnitude to be reflected in vascular disease mortality. There has been found, on the other hand, a continuous relationship between arterial pressure and relative weight throughout the spectrum of weight, despite the general leanness of this population. "

Hospital of St. Raphael, New Haven, Connecticut 06511,

DOCTORS AND SMOKING

U.S.A.

SIR,-No doubt Mr Harris (Dec. 14, p. 1458) is right. We shouldn’t smoke, even us older ones. But for every on smoking there’s one on geriatrics; I don’t know which frightens me more. We all have to find our " own way of resolving Swift’s dilemma: Every man to live long; but no man would be old."

DONALD S. DOCK.

publication

desires

Department of Anatomy, Medical School, Newcastle upon Tyne NE1 7RU.

SIR The report by Dr Everson and others (June 22, 1290) prompted a survival study of 274 Wilms’ tumour patients treated at the Sidney Farber Cancer Center (Children’s Cancer Research Foundation) of Boston in 1945-69. For successive quinquennia after 1945, the 3-year survival-rates rose steadily: 18%, 19%, 48%, 55%, and 67%. The trend paralleled that reported by Dr Everson and his colleagues, even though the two series may have differed in patient selection and treatments. Published reports show nearly flat survival curves for Wilms’-tumour patients following the third year after diagnosis. 1-3 In our series, 14 late deaths have occurred among 140 patients alive at 36 months. Actuarial analysis of the data shows excess mortality up to 25 years, although the small numbers at risk beyond 15 years must be interpreted with caution (see accompanying figure). Cause of late mortality in 4 patients was recurrent Wilms’ tumour, another with trisomy 184 died with an acute infection. 9 others, including 5 who presented with disseminated disease or required multiple courses of therapy, died in p.

J. E. GRAY.

ANTIGENIC SITES RELATED TO HUMAN SERUM-PROTEINS ON HBsAg AND SPECIFICITY OF IMMUNOSORBENTS

SIR,-We read with great interest the letter by Goudeau al.l showing that hepatitis-B surface antigen (HBsAg) may be non-specifically adsorbed to immunosorbents prepared by linking antibodies to ’Sepharose’ 4B. This non-specific binding was also observed in our experiments.2 However, the finding of Goudeau et al. fails to support et

the conclusion that it seems highly improbable that HBsAg particles carry normal serum-proteins on their surface. The reasons are: (1) the authors used HBsAg preparations containing normal human serum-proteins (N.H.S.) which inhibit the immunospecific binding of HBsAg to insolubilised antibodies against N.H.S. 2; (2) the decision whether or not an immunospecific attachment of HBsAg to insolubilised antibodies against components of N.H.s. occurs may be based only on comparative quantitative studies in which insolubilised non-immune y-globulins serve as controls and in which non-specific adsorption of HBsAg is suppressed. Our studies suggest that HBsAg carries antigenic sites related to some components of N.H.S.2 Virology Laboratory, New York Blood Center, New York, New York 10021, U.S.A.

SURVIVAL IN WILMS’ TUMOUR

-

A. R. NEURATH.

sustained remission with treatment-associated disorders. 4 of the 9 developed second neoplasms in irradiated sites," and the remainder had pulmonary (3) or renal (2) failure after treatment of these organs with radical surgery, intense irradiation, and actinomycin D in conventional doses.6 Mortality after the third year thus resulted chiefly from Cassady, J. R., Tefft, M., Filler, R. M., Jaffe, N., et al. Cancer, 1973, 32, 598. 2. Aron, B. S. ibid. 1974, 33, 637. 3. Hussey, D. H., Castro, J. R., Sullivan, M. P., Sutow, W. W. Radiology, 1971, 101, 663. 4. Geiser, C. F., Schindler, A. M. Pediatrics, Springfield, 1969, 44, 111. 5. Li, F. P., Cassady, J. R., Jaffe, N. Cancer (in the press). 6. Jaffe, N., Li, F. P. Radiology (in the press). 1.

OBESITY AND CORONARY-ARTERY DISEASE

SIR,—It to

bear

on

may be worth bringing additional information issues raised by Leelarthaepin et’ al. (Nov. 23,

1217). They alluded to the dispute about obesity as an independent risk factor in coronary-artery disease and stressed the association between food intake, weight, and p.

the known risk factor, serum-cholesterol. Preliminary results from a longitudinal study of Japanese men and women (Atomic Bomb Casualty Commission, Hiroshima and Nagasaki) suggest that, when blood-pressure is removed as a confounding variable, initial relative weight is not correlated with subsequent cardiovascular mortality-rate. The implication of these findings, however, must necessarily be tempered by the realisation that relative weight is by no means the same kettle of fish in 1.

Goudeau, A., Houwen, B., Dankert, J. Lancet, Nov. 30, 1974, p.

2.

Neurath, A. R., Prince, A. M., Lippin, A. Proc. natn. Acad. Sci. 1974, 71, 2663.

1325.

Actuarial survival curve, with 95% confidence intervals, for 140 Wilms’-tumour patients alive at 36 months after diagnosis. Controls are U.S. children of comparable ages.

42

sequelæ of curative therapy for aggressive lesions. The finding indicates the need for long-term evaluation for morbidity as well as mortality in Wilms’-tumour patients.

TABLE II—COMBINED DATA TO SHOW RISK OF R.D.S. AT A GIVEN SHAKE-TEST RESULT

Boston Field Station, National Cancer Institute,

Epidemiology Branch, 35 Binney Street, Boston, Massachusetts 02115, U.S.A. Biostatistics and Epidemiology Divisions,

Sidney Farber Cancer Center, Boston, Massachusetts 02115, U.S.A.

FREDERICK P. LI. YVONNE BISHOP CHRISTINE KATSIOULES. t

between L/s ratios of 1-8 and 2-0. Deaths due to other causes, when stated, included 3 with L/s ratios greater than 2, and 3 with L/s ratios less than 1-5. Another much simpler test that has received some interest is the " shake test " of Clements et aU7 Most workers who have evaluated this test concluded that its value lies as a screening procedure. We have reviewed 17 publications and the combined results of 11 of them are shown in table 11. Some publications were excluded for the same reasons as for the L/s ratio. It seems that there is a slight risk of R.D.S. in infants with amniotic-fluid L/s ratios greater than 2, but (except in diabetic cases) this virtually disappears above 2-5. The shake test appears to be almost as good as the L/s ratio except that the false-negative rate is higher. It seems that a negative shake test is equivalent to an L/s ratio of between 1-5 and 2-0. Donald et al.3 found a relationship between respiratory distress and Apgar score. All of their babies who developed R.D.S. after an L/s ratio of greater than 2-0 also had a low Apgar score at birth. This is a fact that must be considered when assessing these figures.

rate

RISK OF RESPIRATORY-DISTRESS SYNDROME

SIR,-Since the original communication by Gluck et al.l the accuracy of the amniotic-fluid lecithin/sphingomyelin (L/s) ratio as an index of fetal pulmonary maturity, many workers have confirmed or supported this finding.

on

We were particularly interested in the reports of Whitfield2 and Donald et awl. who used their own results to predict the percentage risk of respiratory-distress syndrome (R.D.S.) at a given amniotic-fluid L/s ratio. We felt that a combination of all published results on the L/s ratio would be of use to the obstetrician in assessing the risk of delivering a baby with a low L/s ratio. 48 publications were reviewed and the data from 25 gave the figures in table I. Only those results which were stated to have been obtained within 72 hours of delivery were used. Other results were excluded because the range of values was not stated precisely for both R.D.S. and nonR.D.S. cases or because the same data were included in another publication. A few authors had modified the method for L/s ratio and found it was not satisfactory; these were also excluded. Our own results 4—6 are included with the other data in tables I and II.

We will be glad to supply to those interested references surveyed for tables i and n.

a

list of the

Institute of Obstetrics and TABLE I-COMBINED DATA TO SHOW RISK OF R.D.S. AT A GIVEN

L/S

RATIO

Gynæcology, Queen Charlotte’s Maternity Hospital, Goldhawk Road, London W6.

DAVID HARVEY CHRISTINE E. PARKINSON STUART CAMPBELL.

INADEQUATE MOTHERS

Table i shows the total number of cases at various L/S ratios and the total number and percentage of infants with R.D.S. in each range. Since maternal diabetes appears to increase the risk of R.D.s. in the newborn, diabetic cases with L/s ratios over 2 are also indicated. The right-hand columns of the table give the total stated number of deaths from R.D.s. (or hyaline-membrane disease) as a percentage of all cases. It can be seen that the lower the L/s ratio, the greater the risk of R.D.s. Some centres take 1-8 as the critical value indicating adequate fetal pulmonary surfactant, but there was a 34°o incidence of R.D.s. and 8°o mortality 1. 2. 3. 4. 5.

6.

Gluck, L., Kulovich, M. V., Borer, R. C., Brenner, P. H., Anderson, G. G., Spellacy, W. N. Am. J. Obstet. Gynec. 1971, 109, 440. Whitfield, C. R. Clin. Obstet. Gynœc. 1974, 1, 67. Donald, I. R., Freeman, R. K., Goebelsmann, U., Chan, W. H., Nakamura, R. M. Am. J. Obstet. Gynec. 1973, 115, 547. Dewhurst, C. J., Dunham, A. M., Harvey, D. R., Parkinson, C. E. Lancet, 1973, i, 1475. Dewhurst, C. J., Harrison, R. F., Harvey, D. R., Parkinson, C. E. ibid. 1973, ii, 332. Parkinson, C. E., Harvey, D. R., Talbert, D. G. Biology of the Neonate (in the press).

SIR,—Two letters in your columns have debated whether mothers of abused children should be subjected to constant manipulation at every juncture of their mothering (Nov. 9, p. 1152), or whether adequate protection of a child requires the shorter, simpler, and surer procedure of separating him from his inadequate mother, so relieving her of the burden of unwanted mothering (Nov. 30, p. 1322). Both writers confine the varied and complex determinants of child abuse to " inadequate mothers ". The Work of Elmer,8 Gil,9 and Spinetta and Rigler,10 among others, demonstrates that a simple concept such as " inadequacy " is not sufficient to account for a problem which has many origins in child, adult personality, family, environment, and culture. To attribute to the mother alone the source of the many causes and manifestations of child abuse is to blame one who is herself a victim.ll To argue for a unitary cause and a uniform intervention may be comfortable for the professional who is frustrated by the complexity and ambiguity of these cases. But such 7. Clements, J. A., Platzker, A. C. G., Tierney, D. F., Hobel, C. J., Creasey, R. K., Margolis, A. J., Thibeault, D. W., Tooley, W. H., Oh, W. New Engl. J. Med. 1972, 286, 1077. 8. Elmer, E. Children in Jeopardy: A study of Abused Minors and Their Families. Pittsburgh, 1967. 9. Gil, D. Violence Against Children. Cambridge, Massachusetts, 1970. 10. Spinetta, J. J., Rigler, D. Psychol. Bull. 1972, 77, 296. 11. Ryan, W. Blaming the Victim. New York, 1971.

Letter: Survival in Wilms' tumour.

41 These studies5 were supported by a Special Project grant from the Council for Tobacco Research-U.S.A., Inc. The Wharton School, Regional Science De...
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