Document downloaded from http://www.elsevier.es, day 15/06/2016. This copy is for personal use.
Any transmission of this document by any media or format is strictly prohibited.
Premature cardiovascular disease in chronic
renal failure. Lancet 2000; 356: 14752.
2 Brown NJ, Vaughan DE. The renin-
angiotensin and fibrinolytic systems. Co-
conspirators in the pathogenesis of ischemic
cardiovascular disease. Trends
Cardiovascular Med 1996; 6: 23943.
3 Kohler HP, Grant PJ. Plasminogen
activator inhibitor type I and coronary
artery disease. N Engl J Med 2000; 342:
1792801.
4 Wardle EN. Soy protein diet therapy in
renal disease. Nephron 1998; 78: 32831.
Carbaril for head lice
SirChristine Roffe (May 13, p 1724)1
states that none of the pediculicides in
use in the UK is thought safe for people
with asthma, children younger than 6
months, or for use in contact with
broken skin.
SSL International currently markets
several malathion, carbaril, and
phenothrin-based head-louse treat-
ments in various formulations
alcoholic lotion, aqueous liquid, and
mousse preparations. The alcohol-based
lotions and mousse formulations are not
suitable for use by patients with asthma
or sensitive skin, but the aqueous-based
preparations are especially suitable for
these individuals. We would also like to
draw Roffes attention to the paper by
Dennis and Lee2 which describes the
results of a study to investigate the safety
of malathion-containing head-louse
treatments. They showed no clinical
effect on plasma or erythrocyte
cholinesterase activity with such
products, irrespective of single-dose or
repeat-dose treatments, or whether
applied to damaged or intact skin. The
use of the above preparations in infants
younger than 6 months is not
contraindicated, but they should be
used only under the supervision of a
doctor.
Roffe also states that carbaril
(carbaryl) might be carcinogenic,
quoting the British National Formulary.
The British National Formulary
qualifies this statement with the
following: The Department of Health
has emphasised that the risk is a
theoretical one and that any risk from
the intermittent use of head lice
preparations is likely to be exceedingly
small.3
Finally, we would like to emphasise
that the use of pediculicides is the only
clinically proven method of treating
head-louse infection.
Philip Davies
Medical and Healthcare Information, SSL
International plc, Oldham OL1 3HS, UK
1 Roffe C. Treatment of pediculicosis capitis by
dry combing. Lancet 2000; 355: 1724.
2 Dennis GA, Lee PN. A phase I volunteer
study to establish the degree of absorption
THE LANCET Vol 356 September 2, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
and effect on cholinesterase activity of four
head lice preparations contaning malathion.
Clin Drug Invest 1999; 18: 10515.
3 Joint Formulary Committee. Skin. In: British
National Formulary 39. Bath: The Bath
Press, March 2000: 534.
Authors reply
SirIn my original letter I wrote that
carbaril, malathion, and permethrin are
not thought safe for people with asthma.
On reviewing the sources, I agree that
this is true only for alcoholic but not for
aqueous solutions.
I also wrote that none of the three
treatments was thought safe for children
younger than 6 months. The British
National Formulary states that the
treatment should be used only under
medical supervision in this age-group.
I agree with Philip Davies that
pediculicides are the only treatment for
head lice with proven effectiveness. I
would, however, like to add that the
effectiveness of non-drug methods for
the treatment of head lice has not been
disproved either.
Christine Roffe
Department of Geriatric Medicine, Springfield
Unit, City General Hospital, Stoke-on-Trent
ST4 6QG, UK
Birth size and arterial
compliance in young adults
SirAlan Montgomery and colleagues
(June 17, p 2136)1 found no correlation
between birth size and arterial pulse-
wave velocity, an indirect measure of
arterial compliance, in young adults. In
their study they tested a hypothesis that
retarded intrauterine development may
result in decreased amount of elastin in
the walls of large arteries, which in turn
induces the cascade of
pathophysiological changes that led to
increased blood pressure in adulthood.2
In a study by Martyn and colleagues a
significant association between birth
weight and pulse-wave velocity was
described in middle-aged individuals,
but these data might have been
influenced by the development of
atherosclerosis in the population studied.
Montgomery and colleagues investigated
a younger group of individuals, and so
their findings should not be influenced
by changes in arterial compliance
associated with atherosclerosis.
Quartile (g) N Birth weight (g)
I (13603000) 37 26383 (45753)
II (30203300) 34 3189 (8454)
III (33203750) 35 35334 (11866)
IV (37705100) 36 41325 (33196)
Data are means (SD). MAP=mean arterial pressure; DC=common carotid artery distensibility coefficient; PWV=pulse-wave
velocity.
Large-artery elasticity and mean arterial blood pressure according to quartiles of birth
weight
CORRESPONDENCE
However, both groups studied pulse-
wave velocity in femoral-popliteal-tibial
or radial arterial segments, which
represent arteries of muscular type with
low elastin content. It should be noted
that analysis of pulse-wave velocity in
typical elastic arteries of aorta-iliac
arterial segments did not show a
significant correlation with birth weight.3
Montgomery and colleagues did not
include data on blood pressure; it is well
known that higher blood pressure is
associated with increased pulse-wave
velocity.4
We did a similar study in a group of
142 healthy normotensive (mean arterial
blood pressure 835 [SD 587 mm Hg]),
non-obese (body mass index 217
[259]) volunteers (71 men and 71
women) aged 1924 (2092 [107])
years. We measured large-artery
elasticity by: assessment of the common
carotid artery distensibility coefficient
(DC) with the Wall Track System (Pie
Medical, NL) and by assessment of
pulse wave velocity (PWV) between
carotid and femoral artery with an
automated computer system (Complior,
Colson, F). Statistical analysis was based
on Pearsons correlation coefficient for
different variables and analysis of
variance for comparisons between
quartiles of birth weight.
There was no significant correlation
between birth weight and parameters
of arterial elasticity: distensibility
coefficient, pulse wave velocity, as well
as mean blood pressure. We also could
not detect any differences or correlations
between parameters studied when
participants were analysed according to
sex. The results of the measurements
according to the quartiles of birth weight
are shown in the table.
Our data did not show an association
between birth weight and elastic
properties of the large arteries of high
elastin content in the studied population
of young, healthy people with normal
blood pressure. Also, the participants did
not show a significant relation between
birth weight and mean systolic and
diastolic blood pressure. This lack of
apparent association between birth
weight and blood pressure in young
people was also described by Martyn
and colleagues in 1995.3 However, since
arterial compliance is associated with
intralumen pressure, assessment of
elasticity parameters was more reliable.
DC (kPa1103) PWV (m/s1) MAP (mm Hg)
3946 (781) 781 (101) 839 (682)
4019 (741) 774 (076) 837 (690)
3761 (679) 790 (075) 830 (443)
3735 (711) 813 (094) 833 (515)
855
Document downloaded from http://www.elsevier.es, day 15/06/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
CORRESPONDENCE
Thus, it seems that other factors like
insulin resistance, sympathetic
overactivity, diminished number of
nephrons, or pituitary-adrenal axis
abnormalities may be responsible for the
association between low birth weight
and high blood pressure in adulthood.
G Styczynski, P Abramczyk, C Szmigielski,
G Placha, *Z Gaciong
*Departments of Internal Medicine and
Hypertension and Experimental and Clinical
Physiology, Medical University of Warsaw,
Warsaw 02-097, Poland
e-mail: zgaciong@amwaw.edu.pl
1 Montgomery AA, Ben-Shlomo Y, McCarthy
A, Davies D, Elwood P, Davey Smith G.
Birth size and arterial compliance in young
adults. Lancet 2000; 355: 213637.
2 Martyn C, Greenwald S. Impaired synthesis
of elastin in walls of aorta and large conduit
arteries during early development as an
initiating event in pathogenesis of systemic
hypertension. Lancet 1997; 350: 95355.
3 Martyn C, Barker D, Jespersen S, Greenwald
S, Osmond C, Berry C. Growth in utero,
adult blood pressure and arterial compliance.
Br Heart J 1995; 73: 11621.
4 Matthes JWA, Lewis PA, Davies DP,
Bethel JA. Relation between birth weight at
term and systolic blood pressure in
adolescence. BMJ 1994; 311: 77376.
Mono-ocular occlusion for
treatment of dyslexia
SirIn her July 8 commentary, A J
Fawcett1 makes an attack on the work of
Stein and colleagues2 which showed, in a
well-designed trial, that appropriately
selected people with dyslexia can be
helped to read, by mono-ocular
occlusion. Fawcett gives no evidence
that any appropriate study has failed to
confirm this, so why does she call it
contentious? Her statement that many
questions need to be answered, and her
dislike of a result that does not fit with
her theories show extreme naivet.
Dyslexia is obviously diverse, but
Fawcett deplores the probability that
Steins method will help only some;
those helped will not mind if they are in
that number. She recognises that some
people with reading difficulty have
difficulties with speech too, but some do
not. Those, like me, and my family,
whose dyslexia springs from lack of
visual recall, have no difficulty with
speech; indeed we are very good at it.
Stein probably cannot help us, but
Fawcetts attempt to handle all those
with dyslexia in the same way is clearly
wrong. The written word is a crude and
inefficient way of recording sound, and
we now have better ways of doing so.
Stein is right that reading is still
important, and we welcome what help
we can get with reading, but writing and
spelling are not. Our real educational
(not treatment) needs are more
856
For personal use only. Not to be reproduced without permission of The Lancet.
complex. I think that it is easier to gain
access to the abstract from a sound-
based thought process, than one with a
major visual component, and this
explains the achievement of many
people with dyslexiaEinstein, a
possible example. This is a difference,
not a disability or an abnormality. There
is a need for appropriate education
which develops these differences.
J F Soothill
Pensylvania, Lodge Lane, Axminster,
EX13 5RT, UK
1 Fawcett AJ. Mono-ocular occlusion for
treatment of dyslexia. Lancet 2000; 356:
8889.
2 Stein JF, Richardson AJ, Foweler MS.
Monocular occlusion can improve binocular
control and reading in dyslexics. Brain 2000;
123: 16470.
The poor man cooks with
water
SirIn their May 20 commentary1 on
assessment and management of
functional and ischaemic mitral
regurgitation, John Byrne and colleagues
address an important issue in surgical
cardiology. They point out the
difference in mitral regurgitation (MR)
assessment between transthoracic
echocardiography (TTE) and prepump
intraoperative transeosophageal
echocardiography (TEE) and the
consequent difficulties in deciding
whether mitral valve surgery should be
recommended in patients with MR.
They recommend an algorithm for
decision making regarding mitral valve
surgery, in which intraoperative volume
challenge and manipulation of blood
pressure with intravenous phenylephrine
is used to identify patients with clinically
significant MR. Based on the reports by
Bach and colleagues2 and Grewal and
colleagues,3 the investigators conclude
that MR of ischaemic aetiology or as a
result of intrinsic mitral-valve disease is
downgraded during prepump TEE,
because of the unloading effect of
general anaesthesia.
Downgrading of MR on prepump
TEE does not uniformly occur. We
studied 54 patients with intrinsic mitral
valve disease, some of whom had left
ventricular dysfunction (37%) and
regional wall motion abnormalities.4 MR
was graded as less severe on
intraoperative prepump TEE in only
26% of cases compared with TTE.
There was agreement in MR grading in
54% of cases. In fact, in 20% of cases,
MR was graded as more severe on
prepump TEE. In addition, we
compared the ambulatory and
intraoperative (during general
anaesthesia) blood pressures in our
patients and found that there was no
significant difference between the
ambulatory and intraoperative systolic
blood pressures regardless of the
direction of change in MR magnitude.
Beyond the aetiology of MR, there are
several dynamic factors, which influence
the true magnitude and the
interpretation of MR (ie, heart rate,
rhythm, left ventricular contractility,
myocardial ischaemia, segmental wall
motion abnormalities, and preload and
afterload). In addition to these
physiological variables, there are
technical factors leading to discrepancies
in MR assessment between TTE and
prepump TEE. These include the
sensitivity of the techniques, use of echo-
machines with different ultrasound
characteristics and variable settings,
more than one sonographer, and a wide
range of intra-observer and interobserver
interpetation. While it is laudable to
have an intraoperative approach to
assess MR sensitivity, it should be
evidence based. Volume challenge to
raise the wedge pressure to 1518
mm Hg (to reproduce severe MR during
prepump TEE assessment) might not be
the best approach in patients who have
lower ambulatory filling pressures or
patients with systolic or diastolic
dysfunction in whom left ventricular
filling pressures are higher. Further, the
investigators suggest that the mean
blood pressure should be adjusted to
100 mm Hg, not taking into account the
range of patients blood pressure at rest
as well as during physical activity.
Because of the qualitative nature of
MR assessment and the multiple factors
which influence its severity, one should
be cautious about oversimplifying the
intraoperative assessment by the
uniform recommendation of
manipulation of volume status and
blood pressure. At present, we cannot
influence all of the other factors and we
cannot predict their complex effect on
MR in the individual patient. The
rationale for an algorithm for the
intraoperative management of MR is
clear, but resources are limited, and that
must be recognised. As the Hungarian
proverb goes: the poor man cooks with
water, we can only use resources
available. This simple algorithm may not
provide insight into the real MR
magnitude in the patients daily life. We
believe that recommendation for mitral
valve surgery should be given
preoperatively, and should be based
on a thorough clinical and echo-
cardiographical assessment of MR
severity.
Andrea V Brasch, Steve S Khan,
*Robert J Siegel
*Division of Cardiology, Cedars-Sinai Medical
Center, Los Angeles, CA 90048, USA; and
THE LANCET Vol 356 September 2, 2000