BRITISH MEDICAL JOURNAL VOLUME 293. 30 AUGUST 1986 .... 5 Morris JA, Haran D, Smith A. Hypothesis: common bacterial toxins are a possible cause of ...
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2 Sachdev NS, Carter CC, Swak R1L, Blachly PH. Relationship between post-cardiotomy delirium clinical neurological changes and EEG abnormalities. J Thorac Cardiovasc Surg 1%7;54:557-63. 3 Lee MC, Geiger J, Nicoloff D, Klassen AC, Resch JA. Cerebrovascular coqnplications associated with coronaryartery bypass (CAB) procedure. Stroke 1979;10: 107. 4 Bojar RM, Najafi H, Delaria GA, Serry C, Goldin MD. Neurological complications of coronary revascularisation. Ann Thora3aSurg 1983;36:427-32. 5 Smith PLC, Treasure T, Newman SP, et al. Cerebral consequence of cardiopulmonary bypass. Lancet 1986;i:823-5. 6 Shaw PJ, Bates D, Cartlidge NEF, et al. Early inteilectual dysfunction following coronary bypass surgery. Q J Med
1986;225:59-68.
Inlluence of intrinsic sympathomimetic activity on respiratory function during chronic n blockade SIR,-DrS R J Northcote and D Ballantyne (12 July, p 97) have extended the observation that acute administration of i blockers both with and without intrinsic sympathomimetic activity leads to bionchoconstriction, showing that this reduction in forced expiratory volume in one second (FEVy) is maintained during long term a minstratin. However, other of their conclusions may be invalid. Have they shown that long term i blockade causes a "progressive deterioration in respiratory function"? The changes in respiratory function do not appear to differ significantly from week 2 to week 52 (ps0-80 for both propranolol and pindolol with respect to FEV, and FEV5 (% predicted). Could not the bronchoconstriction shown have been completely reversible on cessation of treatment? Further respiratory function tests during no treatment at the end of the study would be valuable. Until these obserVations have been made no conclusions may thus be drawn on the long term effects of i blockers on respiratory function. ROGER BARTON Department of Medicine, Western General Hospital, Edinburgh EH4 2XU
SIR,-Drs R J Northcote and D Ballantyne seem to raise fresh qUestions about the long term use of f3 adrenoceptor blockade. They note reduction in lung volumes over a year in patients taking fi adrenoceptor antagonists for angina. Data from table II indicate that the fall in forced expiratory volume in one second on propranolol at 52 weeksis 190 ml, in contrast to the figure of 241 ml in table III. This discrepancy makes it difficult to assess the long term effects of propranolol on lung volumes. Lung volumes decline gradually with age'; the reductions are greater in those who are or have been smokers.2 Mild left sided heart failure might also contribute to reductions in lung volumes in these patients. The study confirms previous work (quoted by authors) showing that fi adrenoceptor blockade has an initial adverse but small effect on lung volumes in some non-asthmatic patients. However, a study including a control group would have helped perhaps to distinguish the effects of long term adrenoceptor blockade on lung volumes from that of other vanrables. K E BERKIN
Department o£Respiratory Medicine,
Western Infilrnsry, Glasgow Gil 6NT 1 2
AUTHORS' REPLY-Dr Barton has made the point that we may not have shown progressive deterioration in respiratory function. However, it is clear that the reduction in forced expiratory volume in one second (FEVI) of 241 ml is significantly greater than that at e'ither two weeks or six weeks after the start of treatment with propranolol. This, we feel, allowed us to draw the conclusion that at least propranolol caused a deterioration in respiratory function in terms of FEVI. However, such an effect was not observed with pindolol. It is not possible to comment on whether the broncho-' constriction shown would have been reversible on stoppingtreatment. We did not study these patients at this stage as we felt it might be unethical to do so. The study group were patients with stable angina pectoris whose symptoms improved significantly during , blockade. Stopping this medication was not justifiable in our view. We do not agree, however, that until these observations are made no conclusions can be drawn from long term effects of i blockers in respiratory function. We have clearly shown a long term deterioration in respiratory function in patients taking propranolol and, to a lesser extent, in patients taking pindolol, the latter having a significantly smaller effect in terms of FEVI. We note Dr Berkin's suggestion that lung volumes decline gradually with age and in patients who are or have been smokers. However, in our paper it is clearly stated that the proportion of current and ex-smokers and age distribution between the groups receiving pindolol and propranolol were very similar. In addition, although mild left sided heart failure can result in reduction in lung volume, further data from this study suggested that left ventricular performance measured in terms of left ventricular ejection fraction improved significantly and consistently in those treated with propranolol throughout the study, but no change was found in those taking pindolol. We are therefore unable to accept Dr Berkin's suggestion that mild left sided heart failure may have resulted in the changes in lung volumes experienced in our patient groups and feel that a drug effect was the most likely cause in such a controlled study. ROBIN J NORTHCOTE D BALLANTYNE Department of Medical Cardiology, Victoria Infirmary, Glasgow G42 9TY
hncreased risk of sudden infant death syndrome in older infants at weekends SIR,-Dr M F G Murphy and colleagues (9 August, p 364) confirm in a large series earlier reports' 2 -that sudden infant death syndrome might be more common at the weekend, particularly in older infants. They suggest that these findings are consistent with the conclusions of the Knowelden report3 and that hesitation or diffidence in calling the doctor for apparently minor illness or deficiencies in primary care might contribute to the weekend excess. However, if the concept that failure to recognise and act on minor signs of illness in infants increases the chance of subsequent' death is valid then this implies that the weekend excess is due to relative neglect on Thursday or Friday,;'which would be difficult to explain. Furthermore, the restricted availability of medical care at the weekend should lead to an increase in de'aths on Monday'or Tues-
day, whereas these days have the least number of cases. It'seems more likely that the weekend excess Cotes JE. Lung function. Assesmen and application mz medicin. is due to a more immediate effect of changed Oxford: Blackwell Scientific, 1975. Higgina ITT, Oldbam PD. Ventilatory capacityin miners, a five- parental routine, and one possibility-is that families tend to sleep later at the weekend and infants are year follow-up study. BrJ IndwstrMed 1962;19:6S-76.-
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left for longer in their cots. An explanation for the weekend excess, based on the pooling of infected nasopharyngeal secretions-during sleep, has been proposed.45 This idea can be tested, as it leads to the prediction that those who die at the weekend will be found later than those who die in the week. J A MoRRis Department of Pathology, Lancaster Moor Hospital, Lancaster LAl 3JR I Cameron AH, Asher P. Cot deaths in Birmingham 1958-1%1. Med Sci Lao 19%5;5: 187-99. 2 Working Party for Early Childhood Deaths in Newcastle. Newcastle survey of deaths in early childhood 1974/76 with special reference to sudden unexpected deaths. Arch Dis Child
1977;52:828-35. 3 Knowelden J, Keeling J, Nicholl J. A multicentre tudy of postneonatal mortali. London: DHSS, 1984. 4 Morris JA, Haran D, Smith A. Sudden infant death syndrome and common bacterial toxins: a mathematical model.J Pathol 1985;145: I 134A. 5 Morris JA, Haran D, Smith A. Hypothesis: common bacterial toxins are a possible cause of the sudden infant death syndrome. Medical Hypotheses (in press).
Making dysphoria a happy experience SIR,-Dr C G Ells (2 August, p 317) describes his method of treating the unhappy chronic attender in general practice. He compares the patient to a leaking bucket and the GP to a dustbin. What a counsel of despair. The patient makes Dr Ellis's heart sink because Dr Ellis has in his turn made the heart of the patient sink by continuing to paint over the damp patch on the wall instead of looking for the cause in a trained and scientific way. Two recent cases will illustrate this. A 20 year old woman working as a hospital secretary asked for a repeat of her migraine tablets. She was a new patient to me, registered with the practice for a year, very attractive and well dressed, with a warm friendly personality. She gave a history of three years' recurrent unilateral headache, worse in the past six months, with no premonitory or visual symptoms, aggravated by nothing and slightly eased by paracetamol. I asked whether she was living with her parents? No, with her grandmother. Were her parents alive? Yes, they lived 10 miles away. Slowly the story was encouraged to unfold. Her mother's parents had emigrated to England leaving her mother as an infant to be brought up by her grandmother in Jamaica. Her mother, at the age of 15, had become pregnant 'and had been shipped over to the UK to her unsuspecting parents, with resultant trauma to all concerned. My patient was the illegitimate child of that 15 year old girl and the tale became a classic story of the child reliving the mother's troubled life. She cried a lot as the story continued. Her face lost its warm friendly look and became very sad, as did mine, as gradually we both understood the reason for her "migraine.'' I asked her to return next'week, and she left without a prescription. An 80 year old spinster who lived alone with a multitude of pains and general misery responded well to a discussion about her declining family relationships, especially with her recently widowed sister, who had abused a position of power due to her possession of a husband and child. She still, of course, has the pains of an arthritic spine but tolerates them and life much better. General practice provides the ideal constructive setting for dealing with the dysphoria so ably described by Dr Ellis and perhaps more importantly for preventing that chronic state of "'heart sinking" in both patient and doctor. Despite his genius Sigmund Freud needed to spend years to help his patients; GPs have patients for years. They need consciously to tackle the problems underlying their patients' presenting symptoms. This-needs more than a dustbin; it
