544 absolute and percentage T and B lymphocyte counts, and responses to dinitrochlorobenzene did not differ significantly from controls. These consistently normal results in this group of patients still defy adequate explanation. Individuals within each stage group showed marked variations, which is perhaps not surprising since breast cancer is such a heterogeneous disease. This variation naturally invites speculation,’ but any relevance of these results to disease behaviour and prognosis can only be determined by careful follow-up of individual patients. C. TEASDALE University Department of Surgery, Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN

J. THATCHER R. H. WHITEHEAD M. J. B. CHARE L. E. HUGHES

of secondary hyperparathyroidism with because the mechanism of and normocalcaemia hypercalciuria the hypercalciuria did seem to be an increase in the filtrated load of calcium. We recommend periodic measurements of both plasma and urinary calcium after kidney transplants. If oral phosphates do not lead to a decrease in the urinary calcium then new calculi may form, as they do when this treatment is administered to patients whose urine is persistently alkaline. If hypercalcxmia and/or hypercalciuria persists we would recqmmend subtotal parathyroidectomy. A. CARALPS J. LLOVERAS J. MASRAMON

could be

an

example

Renal Transplant Unit,

Hospital Clinico y Provincial, Universidad de Barcelona, Barcelona 11, Spain

J. ANDREU A. BRULLES

J. M. GIL-VERNET

HAZARDS OF COLONOSCOPY

SIR,-We read with interest the letter by Mr Rees and Dr Williams (Feb. 12, p. 371). We have done over 200 colonoscopy examinations’ and agree that insufflation of compressed air into the colon is not without risk. We would like to report such a complication in one of our patients. A 42-year-old man underwent an uneventful colonoscopic examination. Several hours later large-bowel obstruction developed, and laparotomy revealed a partial volvulus of a distended transverse colon. Air had presumably been trapped between the acute angles of the splenic and hepatic flexures and had caused the volvulus. Decompression of the bowel and relief of the volvulus were followed by complete recovery. Although colonoscopy is a relatively safe procedure in experienced hands,a the hazards of air insufflation must be recognised. Care should be taken to ensure that the colon is deflated during withdrawal of the instrument. Department of Surgery, Royal Victoria Infirmary, Newcastle upon Tyne NE 1

4LP

EFFECTS OF INCUBATOR NOISE ON THE COCHLEA OF THE NEWBORN

SIR,-We should like to ask Mr Douek and his colleagues whether the sound-levels which caused cochlea damage in the guineapig’ were similar to those inside modern, incubators, or similar to those inside headboxes or old-fashioned or malfunctioning incubators. The level of noise to which the guineapigs were exposed seems to us considerably higher than that we have found in three types of incubator used in this country (see accompanying figure): Our findings agree with those reported

previously.23 Douek et al. say that the noise-levels in "incubators and boxes" were measured, although the levels reported in fig. 2 of their paper are said to be those from incubators alone. The noise used to produce cochlea damage was approximately 70 dB up to a frequency of 16 000 Hz, yet the level of incubator noise in modern incubators is generally less than 55dB for frequencies over 1000 Hz.23 We share these workers’ concern that the noise environment 1.

URINARY CALCULI AFTER RENAL

TRANSPLANTATION comment (Feb. 12, p. 343) on the persistence of hyperparathyroidism after successful renal transplantation. In our experience another complication is urinary lithiasis. We have seen seven cases of urinary lithiasis in renaltransplanted patients. In one patient the calculus, which was radiotransparent, originated in the donor. In one it was in the ureter of the recipient before transplantation. In one it was of magnesium ammonium phosphate and was considered to be secondary to a persistent urinary-tract infection by Proteus. In the remaining four the calculi were attributed to a hypercalciuria associated with hypercalcaemia; the hypercalcaemia was temporary in three but persisted for eight years in one, and in this patient arterial calcification developed despite a normal plasma calcium x phosphate product. The renal tubular reabsorption of phosphates was reduced in these four cases. Oral administration of phosphates, which has been recommended for the treatment of post-transplantation hypercalcaemia, lowered calcium concentrations in plasma and urine and increased the urinary phosphate; nevertheless, in one patient in whom a new calculus developed during treatment, urinary and plasma calcium did not decrease though the urinary phosphate rose. In ten other consecutive patients who had received a renal transplant and whose creatinine clearances were higher than 50 ml/min, we studied plasma and urinary calcium periodically. Three of them showed a temporary hypercalcaemia, associated in two with hypercalciuria, and another patient showed a hypercalciuria without hypercalca:mia; this last case

Douek, E., Bannister, L. H., Dodson, H. C., Ashcroft, P., Humphries, K. N. Lancet, 1976, ii, 1110. 2. Gosta Blenmow, Svenningson, N. W., Almquist, B. Pediatrics, 1974, 53, 29. 3. Seleny, F. L., Streczyn, M. Am. J. Dis. Child. 1969, 117, 445.

SIR,-You

uraemic

1. Britton, D. C., 2.

Tregoning, D., Bone, G., McKelvey,

1977, i, 149. Williams, C., Teague, R. Gut, 1973, 14, 990.

S. T. D. Br.

med. J.

Typical sound-levels in three incubators of different manufacby Bruel and Kjaer sound-level meter (solid lines). Broken line is taken from Douek et al.’1 ture, measured

Urinary calculi after renal transplantation.

544 absolute and percentage T and B lymphocyte counts, and responses to dinitrochlorobenzene did not differ significantly from controls. These consist...
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