510 off point in our series being explicable by longer euglobulin lysis-times and more frequent varicose veins. Prediction of postoperative leg-vein thrombosis from a simple set of preoperative clinical and

laboratory data

seems a

valid and useful

approach.

Centre for Thrombosis and Vascular Research, Department of Medical Research,

University of Leuven, B-3000 Leuven, Belgium

St. Rafael for Vandenberghe for assist-

Hospital

ISTVAN RAKOCZI DALTON CHAMONE DESIRE COLLEN MARC VERSTRAETE

PLASMA-SECRETIN DURING FASTING

SIR,-In 1975 we showed that concentrations of plasma-secretin, measured by radioimmunoassay, rose during fasting, the

being significant after 24 h and highest after 72 h. Dr Greenberg and Dr Bloom (Feb. 4, p. 273), also using radioimmunoassay, found no increase in plasma-secretin in a study limited to a starvation period of 24 h. They suggest that the discrepancy may be caused by interference in the assays by products of lipolysis. The antibodies used in the two laboratories seem to have the same regional specificity for a portion of the secretin molecule located towards the C-terminal region increase

of the hormone. 2,3 In further studies in fifty healthy volunteers, fasted for 36 h, we have found significantly increased concentrations of secretin-like immunoreactivity. After an overnight fast (12 h) the

18±3 (S.E.M.)

pg/ml increasing

to

103±12

pg/ml

when the starvation was continued for a further 24 h. This was not a universal response; six volunteers showed no

(p10 bacilli/slide) organisms which records, as suggested by Weinstein et al.,’ pointed to contamination. in the diagnostic laboratory, and distilled water from the hospital central supply was found to be the source of the acid-fast organisms. Filtration of 500 ml of distilled water revealed acid-fast organisms on smear, and cultures grew Mycobacterium gordonae, a common tap-water contaminant. The distilled water had been autoclaved before use in processing specimens, rendering the mycobacteria non-viable. However, they remained acid fast, thus accounting for the positive smears with negative cultures. Filter sterilisation of solutions used in processing specimens eliminated false-positives, and all specimens that had positive acid-fast smears in the subsequent month also had growth of mycobacteria on culture. The acid-fast smear remains a valuable aid in the early presumptive diagnosis of tuberculosis.3 However, false positives must be avoided. In one series of false-positive acid-fast smears a water deioniser contaminated with M. gordonae was incriminated.4 My findings demonstrate that hospital distilledwater systems may also be a source of contamination, and emphasise the need for regular monitoring of water used to process mycobacterial specimens, by membrane filtration or centrifugation.4 The contamination was traced to a central distilled water reservoir, which had not been cleaned according to schedule. After the reservoir was cleaned the water was free of

mycobacteria. The value of the acid-fast smear has come into question with the report of 55% false-positive results from a prominent hospital laboratory.5 However, another laboratory found only 3% false-positive acid-fast smears.3 Contamination may explain this discrepancy: the high false-positive rates reported by some laboratories may be due to non-viable mycobacteria in solutions. Membrane filtration of solutions for processing mycobacterial specimens should be standard procedure. Veterans Administration

Hospital, Department of Pathology, University of Utah Medical School, Salt Lake City, Utah 84148, U.S.A.

MICHAEL T. KELLY

TREATMENT OF PAROXYSMAL ATRIAL TACHYCARDIA BY DIVING REFLEX

SIR,-Early reports of treatment of paroxysmal atrial tachycardia (P.A.T.) using the diving reflex (immersion of face in cold water while the breath is held)6 have been encouraging. I would like to report experience with this method in ten patients (aged 22-66) who presented with definite P.A.T. established by electrocardiography. Six were women and five had a history of P.A.T. Four were on maintenance digoxin, propranolol, or quinidine alone or in combination. Four had underlying coronary-artery disease with previous myocardial infarction. Carotid-sinus massage had been tried unsuccessfully in all ten patients. The diving reflex was attempted by the method previously described,6 and six patients converted to sinus rhythm in 10-25 s. In one unsuccessful case the patient could not keep his face immersed for more than 8 s. The average age of patients who responded was 46 years: the non-responders were older 1. Weinstein, R. A., Stamm, W. E., Anderson, R. L. Lancet, 1975, ii, 173. 2. Tsukamura, M. Am. Rev. resp. Dis. 1970, 102, 643. 3. Pollock, H. M., Wieman, E. J. J. clin. Microbiol. 1977, 5, 329. 4. Dizon, D., Mihailecu, C., Bae, H. C. ibid. 1976, 3, 211. 5. Boyd, J. C., Marr, J. J. Ann. intern. Med. 1975, 82, 489. 6. Wildenthal, K., Atkins, J. M., Leshin, S. J., Skeleton, C. L. Lancet, 1975,

i, 12.

511

(61) and had evidence of pre-existing cardiac disease. One young patient with recurrent P.A.T. was taught self-induction of diving reflex by facial immersion and reported prompt response, with fewer emergency visits to hospital. We encountered no complications of this treatment. Even though this method is not recommended for atrial fibrillation, it was attempted inadvertently on a 64-year-old man with type B Wolff-Parkinson-White syndrome and aortic stenosis who presented with atrial fibrillation and very rapid ventricular response. Treatment resulted in further increase in ventricular response and widening of QRS complexes, requiring immediate electrical cardioversion. The frequency of successful conversion is lower in our series than in others, but the diving reflex was attempted only after carotid-sinus massage had failed so these patients represent a group resistant to a more conventional method of treatment. Induction of diving reflex is a safe and efficient method of converting P.A.T., especially in younger patients without significant organic heart-disease, even when conventional vagotonic manreuvres such as carotid sinus massage have failed. School of Medicine and Dentistry, University of Rochester and St Mary’s Hospital,

Rochester, N.Y. 14611, U.S.A.

Commentary From Our

P. K. MATHEW

from Westminster

Parliamentary Correspondent

Mr Ennals Sticks to his Priorities Mr David Ennals, Secretary of State for Social Services, and the British Medical Association are still on

speaking terms. That much at least can be said, but little more, after a meeting between the two sides last week. the House of Commons Mr Ennals the B.M.A. to hear their critithe Health Service. At the end the two sides were still as far apart as before. Indeed, so fixed were some of the views that Mr Ennals actually issued his statement about the meeting before it took place. He reaffirmed his determination to stand by his priorities for the health and personal social services, although he said he had no intention of pushing change, particularly in the acute hospital sector, faster than was tolerable within the level of resources available. He urged the medical profession to resist the temptation to over-react by exaggerating the effects of his strategy. The deputation was not exactly impressed with what it heard, and the B.M.A. later made it clear that it too was standing firm on its view. It is highly critical of the strategy to shift the balance of priorities in favour of the services for the elderly, for the mentally ill and handicapped, and for children. Although it describes these aims as praiseworthy and humane, it questions whether they should be pursued at a time of general economic reFor 90 minutes

at

deputation* from cism of his priorities for

met a

*The deputation consisted of: Mr Anthony Grabham, chairman of the Central Committee for Hospital Medical Services; Dr Bob Milsted, chairman of the Hospital Junior Staffs Committee; Dr Tony KeableElliott, chairman of the General Medical Services Committee; Dr Stuart Horner, chairman of the Central Committees for Community Medicine; and the Chairman of Council and the Secretary of the B.M.A., Dr James Cameron and Dr Elston Grey-Turner.

straint. It remains particularly concerned about the Government’s policy of slowing down the expansion of acute services. In a recent letter to the B.M.A. Mr Ennals admitted that there would be a price to pay for this policy. Some hospitals would have to continue to manage with outdated or inadequate facilities, the expectations of the professions and of users of the service would not be fully satisfied, and the provision of some new facilities would have to be postponed. The Government’s claim that it is still providing additional money in real terms for acute hospital services is not disputed by the B.M.A. But the Association says this does not alter the dilemma of the individual consultant in his efforts to maintain standards with inadequate resources. For some time concern has been growing about the effect of the Government’s policies on medical standards. The Joint Consultants Committee expressed its grave anxiety last October when it set up a special group to investigate the difficulties facing doctors in their struggle to maintain standards. The B.M.A. regards as particularly significant Mr Ennals’ recent admission that resources for the N.H.S. do not meet its needs. The D.H.S.S. reply is that it has all been said before in different ways. But the B.M.A. clearly believes it has wrung an important admission from the Secretary of State which strengthens the B.M.A.’s own views on alternative methods of financing the N.H.S. But this only divides the two sides even further, since the Government is still officially committed to the abolition of all prescription charges as soon as resources permit. Of more immediate relevance to the problems facing consultants is a new group of senior D.H.S.S. officials and representatives of the Joint Consultants Committee set up to discuss issues of concern to the medical profession. The group, due to meet for the first time this week, is planned as an informal body to give consultants a much earlier say about the formation of Government policy. It is accepted within the D.H.S.S. that too short a period has been allowed for comment on recent statements of Government policy and that an informal group would be a better consultation method. One of the first issues to be discussed will be the Government’s new planning guidelines to be published shortly. So Mr Ennals is sticking firmly to his priorities, but he wants the talking to go on about the details of his strategy. The Braine Bill After the White Bill of 1975 and the Benyon Bill of 1977, we now have the Braine Abortion (Amendment) Bill--the third attempt to change the 1967 Act. By sheer coincidence last week’s Commons vote on whether to allow Sir Bernard Braine to introduce his Bill followed a pattern of annual Parliamentary divisions on the issue. On each occasion M.p.s have voted in favour of measures to tighten up the law, but the anti-abortion majority has dwindled. In 1975 the White Bill got its second reading by a majority of 115. A year later the Bill was sent to a Select Committee by a majority of 140. But last February the Benyon Bill survived by a majority of 38 and last week the Braine Bill squeezed through by just 6 votes. The main purposes of the Bill are to set an upper time limit of 20 weeks for abortions, to strengthen the provisions about conscientious objection, and to ensure that