487 tion and hepatic copper content may be observed in other of chronic hepatitis, whereas the serum-caeruloplasmin is invariably normal or raised in these other conditions. We conclude that, despite its low incidence, Wilson’s disease should be kept in mind when dealing with young patients who present with chronic active hepatitis. causes

ARCHER R. D. H. MONIE

G. J.

Stepping Hill Hospital Stockport SK2 7JE

EARLY DIAGNOSIS OF CONGENITAL ADRENAL HYPERPLASIA

SiR,-We

have

measured

serum

concentrations

of

17-OH-progesterone (17-OHP) serially during the early newborn period in a male infant. The infant was studied because of a family history of congenital adrenal hyperplasia. There was spontaneous onset of labour at 40 weeks, but delivery was by cxsarean section because of fetal distress. At birth, clinical examination was entirely normal. Serum-17-OHP concentrations, determined by radioimmunoassay, were: mixed cord blood 183 nmol/1 and 2, 8, and 16 h and 5 day values 4$, 42, 15, and 3 nmol/1, respectively. The raised concentrations in cord blood and during the first few hours of life presumably reflect the placental production of 17-OHP. Thereafter, the concentrations fell rapidly to normal, thus excluding a diagnosis of congenital adrenal hyperplasia secondary to C21-hydroxylase deficiency. These results are in striking contrast to those obtained from a male infant with congenital adrenal hyperplasia. Mixed cord serum-17-OHP concentration was 225 nmoi/1, and at 2, 8, and 16 h and 5 days age the levels were 109, 188, 488, and 188 nmol/1, respectively. The raised 17-OHP concentrations persisted after birth; subsequently, biochemical confirmation of congenital adrenal hyperplasia was further substantiated by increased urinary excretion of 17-oxosteroids and pregnanetriol. The 17-OHP assay should be of value in the early diagnosis of congenital adrenal hyperplasia due to C21-hydroxylase deficiency, especially in newborn males in whom clinical examination is usually entirely normal. Tenovus Institute for Cancer Research, Welsh National School of Medicine, Cardiff CF4 4XX

IEUAN A. HUGHES

Neonatal Unit, St David’s Hospital, Cardiff

D. H. WILLIAMS A. D. BIRCH

UPPER GASTROINTESTINAL HÆMORRHAGE

S)R,—The interesting article by Dr Franco and her colleagues (Jan 29, p. 218), highlighting the association between stress factors and acute drug-independent mucosal erosions in hepatic cirrhosis, should increase our understanding of the pathogenesis of acute upper gastrointestinal haemorrhage in this condition and help in correct management. We have seen a very similar pattern in patients with fulminant hepatic failure admitted to the acute liver-failure unit, King’s College Hospital. In a series of 105 consecutive cases, 54% developed severe upper gastrointestinal bleeding from acute mucosal erosions.’ There was a significant correlation between hmmorrhage and the complications of hypotension, renal failure, cardiorespiratory distress, and sepsis, similar stress factors to those described by Dr Franco and her colleagues. However, where there is haemorrhage from acute erosions in patients with chronic liver disease and gastro-oesophageal varices, the definition of the predominant site of bleeding is more difficult. In our experience there are three additional possibilities to be considered. Firstly, because variceal bleeding is often 1.

Bailey, R. J., Macdougall, B.

R.

D., Williams, R. Gut, 1976, 17, 389.

intermittent, an initial emergency endoscopy may reveal active

haemorrhage from acute erosions only, whereas repeat endoscopy for subsequent haemorrhage, often within a few hours, may then demonstrate variceal haemorrhage in addition to erosions. Secondly, endoscopy in bleeding patients is notoriously difficult, and haemorrhage from a gastric varix high in the fundus of the stomach may be overlooked in the presence of bleeding mucosal erosions. Thirdly, liver function may deteriorate rapidly after variceal haemorrhage, and this, in addition to other stress factors, may lead to the development of acute mucosal erosions. We would advocate caution in the interpretation of bleeding from acute erosions in these patients. After the start of definitive therapy for gastrointestinal haemorrhage, either from varices or erosions, repeated assessment is essential because the pattern of bleeding may alter from one episode to the next. B. R. D. MACDOUGALL K. J. MITCHELL Liver Unit, P. G. WHEELER King’s College Hospital, ROGER WILLIAMS London SE5 9RS

MULTIPLE SCLEROSIS AND DOGS

StR,—The evidence increasingly favours a viral aetiology for multiple sclerosis (M.s.).’ None of the hypotheses,2-4 however,

explain the epidemiological -data satisfactorily. particular, the positive correlation of M.s. prevalence with latitude is unlikely to be due to sanitary conditions2 or diet,3 since the same correlation is found in areas (e.g., U.S.A., Western Europe, Australia) where living standards and styles vary seems to me to

In

little with latitude. I should like

to

propose

an

alternative

hypothesis. I postulate that dogs are the main carriers of the M.s. virus and that, as in canine hepatitis, the virus is transmitted among dogs via urine. Dogs are particularly prone to inhale material from the urine of other dogs, but often long after the urine has been excreted. Thus, if we assume that the virus in canine urine is inactivated by sunlight, we can account for the correlation with latitude. In Japan, where ns.s. is very rare even in northern areas,7 dog ownership8 runs at a third to a fifth of that in Britain and the U.S.A. Furthermore, in Japan "it is not customary to exercise dogs."8 If M.S. infection in dogs has a long incubation period, then because dogs have a relatively short life each dog carrying the virus might act only briefly as a source of infection. Thus, the infection focus for man would be mainly restricted to the immediate family owning the dog. The age-distribution of M.S. patients, suggests that susceptibility to infection is highest during childhood and adolescence, which would explain much of the data of familial incidence. Thus, the risk for two siblings is much higher,9 because they face common exposure during the short infectivity of a family dog. The increased incidence among cousins9 is also consistent with the hypothesis, since cousins can be expected to visit fairly frequently and to have contact with the family dog. The increase in dog ownership with affluence could also account for its correlation with M.s. 11 among social groups within a country. 10 Carp, R. I., Merz, G. S., Licursi, P. A. Infect. Immun. 1974, 9, 1011. Poskanzer, D. C., Schapira, K., Miller, H. Lancet, 1963, ii, 917. 3. Swank, R. L. A Biochemical Approach to Multiple Sclerosis. Springfield, Illinois, 1961. 4. Alter, M. Lancet, 1976, i, 456. 5. Acheson, E. D. in Multiple Sclerosis: a Reappraisal (edited by D. McAlpine, C. E. Lumsden, and E. D. Acheson); p. 55. Edinburgh, 1972. 6. Poppensiek, G. C., Baker, J. A. Proc. Soc. exp. Biol. Med. N.Y. 1951, 77, 1. 2.

279. 7. Okmaka, S.,

McAlpine, D., Miyagawa, K., Suwa, N., Kuroiwa, Y. Shiraki, H., Araki, S., Kurland, L. T. Wld Neurol. 1960, 1, 22. 8. Carding, A. H. J. small Anim. Pract. 1969, 10, 419. 9. Schapira, K., Poskanzer, D. C., Miller, H. Brain, 1963, 86, 315 10. Miller, H., Ridley, A., Schapira, K. Br. med. J. 1960, ii, 343. 11. Beebe, G., Kurtzke, J. F., Kurland, L. T., Auth, T. L., Nagler, B. Neurology, 1967, 17, 1.

488 The failure to detect M.S. in the dog may be due to the long incubation period and the similarity between symptoms of M.S. and signs of old age in the dog. Thus it might be worthwhile to undertake a search for a possible correlation between M.S. and dog ownership during the childhood of the patient. Department of Biochemistry, McMaster University Medical Centre, 1200 Main Street W., Hamilton, WILLIAM W.-C. CHAN Ontario, Canada L8S 4J9

The risk

SiR,—The subject of Britain’s medical manpower needs is of great importance to everyone in the National Health Service, and I was interested to read (Jan. 29, p. 267) that Sir

Cyril Clarke questions the Government’s present policy of increasing the output of our medical schools. Your report refers to the need to increase the efficiency of consultants and general

practitioners in order to compensate for the standstill in their numbers, and specifically to the greater use of "ancillary workers such as nurses, chemists, and health visitors". Since when have nurses and health visitors been classified as ancil-

lary workers? (The chemists will no doubt make their own comment.) The paragraph concludes: "But Sir Cyril notes how tactfully this approach must be pursued, since the doctors are already much concerned at the erosion of their responsibilities". A little more tact might be a good thing all round.

score

STATUS

SIR,-The article by Holme

et

al.

of great interest

was

to

Over

approximately the same period (September, 1972, to May, 1974) comparable data were collected in the Belgian heart-disease prevention project. As a part of this study, all men aged 40-59 years employed by fifteen Belgian factories were invited to attend a cardiovascular screening. The participation-rate was 87%. Educational level and occupational class were found highly correlated. Coronary risk factors by occupational class are presented in the table.

in the

Belgian study

includes age,

smoking

habits, cholesterol, blood-pressure, and job activity; the important difference in serum-cholesterol between occupational classes contributes largely to the positive relation between risk score and professional class. These opposite results with regard to risk prediction will be of interest when data on coronary-heart-disease incidence in both studies are available. Department of Cardiology, University Hospital, Ghent, Belgium

G. DE BECKER M. KORNITZER C. THILLY

Ecole de Santé Publique, University of Brussels

CHOLESTYRAMINE IN HYPERCHOLESTEROLÆMIA

A. P. LITTLE

CORONARY RISK FACTORS AND SOCIOECONOMIC

us.

between class and serum-cholesterol; however, the cholesterol levels are significantly lower in all Belgian classes than in Norwegians. These differences cannot be accounted for by differences in methods. Since Holme et al. probably recruited their men from the city of Oslo while the Belgian prevention project involves factories in rural areas as well as in cities, this difference could eventually lead to a difference in results. However, the positive correlation between cholesterol and professional class was found both in Brussels and in the rural areas of Bel-

gium.

NURSES NOT ANCILLARY

Northumberland Avenue, London E12

regard to cholesterol, the two sets of results are completely opposite. We have found an important positive relation With

SIR,-Like Dr Farah and his colleagues (Jan. 8, p. 59) we have studied the response of serum-cholesterol to varying doses of cholestyramine given twice daily to children with familial hypercholesterolaemia, but our results differ in several respects. The finding of Farah et al. that the total dose required to achieve a therapeutic effect is independent of body-weight was not apparent in our data, which show a positive correlation

CORONARY RISK FACTORS AND PROFESSIONAL CLASS

,

z

02

04L, Dose of

06

z

088

10

;2

Chotestyramine (g/ kg/day)

Effect of cholestyramine dose

on serum

cholesterol in 22 children

with familial hypereholesterolfemia.

s

a

I

’Age-adjusted. Between our data and those of the Oslo study there are both resemblances and differences. The trends with regard to cigarette smoking were similar in both studies: percentage of cigarette smokers decreased and of ex-smokers increased with occupational class; and the percentage of never-smokers also increased with occupational ciass. However, cigarette smoking in general is more prevalent in all Belgian social classes compared with the Norwegians.

between reduction in serum-cholesterol and the dose of cholestyramine expressed on a body-weight basis (figure). We have also found that reduction in cholesterol concentration for a given dose of cholestyramine is independent of whether or not the patient was on a low saturated-fat diet, at least in the dosage range for which we have most data, from 0.3 to 1-Og/kg. At lower cholestyramine dosage dietary modification (as used by Farah et al.) may have a synergistic effect; however, in our experience long-term compliance with dietary treatment is poor, and we have found that cholestyramine treatment without dietary restriction is much more acceptable.1 In our initial study2 mean pre-treatment serum-cholesterol concentration in the 19 children treated was 377 mg/dl, and thus they were more severely affected than the patients of 1. West, R.

1.

Holme, I., Helgeland, A., Hjermann, I., Lund-Larsen, P. G., Leren, P. Lancet, 1976, ii, 1396.

J., Fosbrooke, A. S., Lloyd, J. K. Postgrad. med. J. 1975, 51, suppl. 8, p. 82. 2. West, R. J., Lloyd, J. K. Archs Dis. Childh. 1973, 48, 370.

Multiple sclerosis and dogs.

487 tion and hepatic copper content may be observed in other of chronic hepatitis, whereas the serum-caeruloplasmin is invariably normal or raised in...
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