204 duced by the neuroleptics.

Higher doses of piribedil would then activate postsynaptic receptors, producing the expected effects of increased dopaminergic transmission at the synapse. This mechanism is consistent with the increasing evidence for the existence of presynaptic receptors or autoreceptors on various aminergic neurons3 10 11 and might explain the paradoxical effects of low doses of apomorphine and piribedil in producing hypoactivity and blocking the motor stimulation of ethanol. 3-5 We have reported elsewhere that higher doses of piribedil (180-240 mg/day) were associated with antidepressant effects in some patients12 and the activation of recurrent manic episodes in one individual.13 This and other data suggest that, in some patients, activation or triggering of mania may involve dopaminergic mechanisms. The antimanic effects of low-dose piribedil might be explained by preferential action on presynaptic dopaminergic receptors and, in effect, reduction of dopaminergic transmission at the synapse. Cools et al.14 postulated the existence of two types of dopamine receptors and suggested that piribedil may act as an antagonist on one receptor system. Cools’ data, in conjunction with the recent report of Creese et al.11 that dopamine receptors may exist in agonist and antagonist forms, offer alternative explanations for the paradoxical effects of low doses of piribedil on behaviour. The data in these 2 patients, in any case, suggest that lowdose administration of a dopamine-receptor agonist clearly does not exacerbate, and may even improve, manic symptoms. If clinically important effects of low-dose piribedil are demonstrated in further studies, this approach may offer a new pharmacological strategy for the treatment of some psychiatric more

fully

patients. Adult Psychiatry Branch, Section on Psychobiology, National Institute of Mental Health, 9000 Rockville Pike,

Bethesda, Maryland 20014, U.S.A.

ROBERT M. POST ROBERT H. GERNER JOHN S. CARMAN WILLIAM E. BUNNEY, JR.

PSYCHOGERIATRIC PATIENTS WHO DIE IN HOSPITAL to prove with his statistics from Stone House Hospital. That demented old people die from physical disease is hardly surprising. To conclude, therefore, that they should be in geriatric and not psychiatric accommodation is to my mind a non sequitur. Surely, if a demented old person has a behaviour disorder such as aggression or wandering, or is paranoid or hallucinated without having any physical disease requiring geriatric medical treatment, then he or she needs to be cared for by people who can, we hope, better cope with them in this condition.

ing

Bolton General Bolton BI4

Hospital, R. TEPPER

0JR.

WHY DO YOU WRITE?

SiR,—The number of medical papers published is

mon-

How much has one really learned from last year’s erratic efforts to read journals? And think of all the work involved in producing the published and the unpublished papers, the millions of blood-samples, and the laboratory tests, and of all the assistants, medical and paramedical, who had to be employed; and think of all the people who were measured and tested as controls. Was the primary object of all this to improve strous

large.

12. Post, R.

practitioners. It seems to me that we should, for an experimental period of a year, declare a moratorium on the appending of authors’ names and of the names of hospitals to articles in medical journals. Just print the article. If the dissemination of information is the reason why papers are submitted for publication, there will be no falling-off in the numbers offered. If the honest search for better treatment is the object of trials, there will be no lessening of the amount of tests and measurements performed in hospitals. But if there is a big saving in costs in the Health Service and far less material is offered to the journals, we shall have unmasked ourselves. 5 Claremont Villas,

Glenageary, Co. Dublin, Ireland.

J. B. HEALY

HEPATITIS-B IMMUNOGLOBULIN IN PREVENTION OF HBs ANTIGENÆMIA IN HÆMODIALYSIS PATIENTS

SIR,-Dr Desmyter and his colleagues (Aug. 30, p. 377) reported that hepatitis-B immunoglobulin (HB Ig) significantly protected haemodialysis patients against HBs antigentmia. In a controlled study, we reached the same conclusion when we used HB Iglin our heemodialysis patients. Patients eligible for the trial had neither HBsAg nor anti-HBs and no past history of hepatitis-B infection; and they were dialysed for less than one month. They were randomised into two groups: (a) HB Ig-treated patients received a dose of HB Ig of 0.08 ml/kg every five weeks for six months and every two months thereafter; (b) control patients received no immunoglobulin. Sera were screened monthly for HBsAG and

anti-HBs, as described. 1-2

patients entered the trial for periods ranging from three fifteen months (mean eight months). None of 9 HB Igtreated and 7 of the 10 control patients developed HBsAg (a23yw) within two-and-a-half months after the beginning of the trial (P

Letter: Why do you write.

204 duced by the neuroleptics. Higher doses of piribedil would then activate postsynaptic receptors, producing the expected effects of increased dopa...
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