Volume 70 June 1977

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Letters to the Editor Epilepsy in General Practice From Dr L S Lange Harley Street, London WI Sir, I am delighted to see that Sheridan Russell is still mounting a spirited attack against maltreatment of epilepsy by overmedication (April Proceedings, p 265). His practical and common-sense advice has been of inestimable value not only to many patients but also to generations of junior staff at Queen Square. The estimation of blood anticonvulsant levels has been a considerable advance in the management of epilepsy but its availability is still restricted because of financial constraints. This merely underlines Dr Dowling's gloom (p 266) about the gradual attrition of facilities available to care for epileptic and other disabled patients, ostensibly to apply more advanced social concepts of community care. Is it too cynical to believe that our paymasters hope for more voluntary charitable organizations to pull these chestnuts out of the fire? Perhaps if epilepsy were as fashionable as migraine, clinics and 'centres' might spring up like mushrooms. Dr Dowling's omission of electroencephalography (EEG) as an essential for the diagnosis of epilepsy is perhaps deliberate in view of the limited value of this investigation; a normal result cannot exclude the diagnosis and a generalized nonspecific abnormality does not establish it. However, despite these limitations EEG may be helpful in confirming the diagnosis of a disease carrying such important medical and social implications. It is occasionally pathognomonic in certain symptomatic epilepsies, and has the added value of being entirely harmless and painfree. In addition to the history, physical examination and investigations proposed by Dr Dowling, in every patient presenting with epilepsy I would wish to have serology for luetic infection, an EEG, and ideally, computerized tomographic scanning (EMI scan) where there is any suggestion that the epilepsy may be other than constitutional. Hospital referral would seem to me to be obligatory not only for a second opinion but also for the specialized investigations which are not directly accessible to general practitioners. I would strongly support Dr Dowling's view that the management of epilepsy should rest with the family doctor if he is interested in the problem. Hospital outpatient clinics may well provide an inadequate service as a result of changing faces and

standards ofjunior staff. The family doctor is also ideally placed to know the full social circumstances and although polypharmacy is rightly condemned there are times when an exacerbation of epilepsy is clearly due to psychological factors and the addition of a tranquillizer to allay anxiety may be enough to control the attacks. The failure of district general hospitals to implement the excellent recommendations to establish epilepsy clinics is probably yet another sign of our penurious times. It is difficult to see this being achieved on an appropriate scale by merely reapportioning the funds. Perhaps this may materialize in the coming golden decade we have been promised. Yours sincerely LEO LANGE

7 April 1977 Natural History of Significant Bacteriuria From Professor P Kincaid-Smith University of Melbourne, Royal Melbourne Hospital, Victoria, Australia 3050 Dear Sir, The editorial on the natural history of significant bacteriuria (March Proceedings, p 149) highlights several important facets of this entity. It is gradually becoming clear that the major risk of bacteriuria in pregnancy is the likelihood that acute pyelonephritis will develop in about 40 % of patients. Nonpregnant women with bacteriuria are very unlikely to develop acute pyelonephritis and the long-term follow up of both pregnant and nonpregnant women suggests a benign course. In childhood, symptomatic or asymptomatic urinary tract infection may not have such a benign course. 'Pyelonephritic' scars have for practical purposes only been shown to develop during childhood when both infection and reflux are present. Although Rolleston et al. (1974) showed progressive scarring without continuing infection, the children in his series had had infection at some time and the time which it takes for a scar to contract down fully is not yet known. Smellie & Normand (1969) observed progressive scar formation accompanying symptomatic infection and vesicoureteric reflux. Filly et al. (1974) and Lenaghen et al. (1972) have recorded a disturbing high risk of progressive scar formation in children with reflux and infection. Both these were, however, selected groups

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attending hospital. The group of bacteriuric schoolgirls detected by screening (Jones et al. 1975) may represent a group with less serious disease and hence a lesser longterm risk. The results of longterm follow up in this group and other similar groups is awaited with great interest. Radiographs four years after detection have apparently not revealed evidence of new damage due to the persistent bacteriuria and reflux. If this proves to be correct on longer follow up there must be some important differences between these bacteriuric schoolgirls and the patients reported by Smellie & Normand (1969), Filly et al. (1974) and Lenaghan et al. (1972). Professor Asscher mentions some of the possible differences in host-parasite relationships. In addition such factors as the degree of vesicoureteric reflux and in particular the presence of intrarenal reflux may well be important. The degree of reflux is very dependent upon urine flow. Reflux which is present when a study is carried out following overnight dehydration is always reduced and often disappears when diuresis is induced (Fairley & Roysmith 1977). Hodson's studies have demonstrated the undoubted role which intrarenal reflux plays in experimental scar formation in the pig (Hodson et al. 1975). Intrarenal reflux is also an important factor in children (Rolleston et al. 1974) and this phenomenon is rarely encountered over the age of 4 years. The bacteriuric schoolgirls in the study of Jones et al. (1975) were all older as are most of the children included in similar studies. Some assessment of the risks of vesicoureteric reflux and of infection in infants and children younger than 4 years is necessary before definitive decisions are reached about the value of screening for urinary tract infection in different age groups. Screening of schoolgirls is almost certainly less valuable than screening an infant group. Yours sincerely PRISCILLA KINCAID-SMITH

10 March 1977 REFERENCES Fairley K F & Roysmith J (1977) Medical Journal of Australia (in press) Filly R, Friedland G W, Govan D E & Fair W R (1974) Radiology 113, 145 Hodson C J, Maling T M, McManamon P J & Lewis M G (1975) British Journal of Radiology Suppl. 13 Jones E R V, Meller S T, McLachlan M S F, Sussman M, Asscher A W, Mayon-White R T, Ledingham J G G, Smith J C, Fletcher E W L, Smith E H, Johnston H H & Sleight G (1975) Kidney International 8, Suppl. 4, S85-S89 Lenaghan D, Cass A S, Cussen L J & Stephens F D (1972) Journal of Urology 107, 755 Rolleston G L, Maling T M J & Hodson C J (1974) Archives of Disease in Childhood 49, 531-539 Smellie J & Normand I C S (1969) In: Urinary Tract Infection. Ed. F O'Grady & W Brumfitt. Oxford University Press; pp 123-135

Management of the Injured Ureter From Mr J C Smith The Radcliffe Infirmary, Oxford, OX2 6HE Dear Sir, Professor Blandy and Dr John Anderson are to be congratulated on the excellent results they acheived in their management of injuries of the ureter using the Boari flap (March Proceedings, p 187). It is worth commenting, however, that such operations are not always technically easy in the presence of severe inflammation in the pelvis following urine leakage and the creation of a flap may be difficult in a small capacity bladder. Transuretero-ureterostomy, on the other hand, is technically easy, is performed in tissues unaffected by previous operations or pelvic radio-

therapy and produces comparably good results. The main problem is that surgeons are reluctant to perform the operation for fear of damage to the normal site. We reviewed the British experience in this operation (Smith I B & Smith J C 1975, British Journal of Urology 47, 519-523) and of the 141 operations performed only 4 failed due to wrong indications or techniques. These results show that transuretero-ureterostomy is a satisfactory alternative to the Boari flap and both are preferable to nephrectomy. Yours sincerely, J C SMITH

3 March 1977

Outpatient Thyrography: Its Value in the Diagnosis of Thyroid and Mediastinal Lesions From Associate Professor S A Smyrnis Evangelismos Hospital, Athens, Greece Dear Sir, I read with interest the article by Dr Galvin and Mr Devlin in the November Proceedings (p 848) on outpatient thyrography. Our own experience on the subject extends to a vast number of patients. Of these, 81 form the clinical material for our paper on 'Thyrolymphography' (Smyrnis S A, Kolios A S, Katsas A G, Spanos H S & Vlachos J D, 1975, American Journal of Surgery 129, 646). Our results are in concurrence with the findings of Galvin & Devlin and also provide an answer to their statement that further work would be required to correlate the results of thyrography with isotope scanning. We compared these results and found thyroid lymphography equal to isotope scanning in accuracy of detection ofnodules and diffuse goitres, and superior in accuracy of detection of multinodular goitres. Its diagnostic accuracy was also equal to or, more often, superior to scanning. As regards ultrasonic scanning, we have no data of correlation as we did not use this method. Yours sincerely S A SMYRNIS

10 March 1977

Natural history of significant bacteriuria.

Volume 70 June 1977 441 Letters to the Editor Epilepsy in General Practice From Dr L S Lange Harley Street, London WI Sir, I am delighted to see tha...
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